Rob Lawrence: Hello and welcome back to another edition of the EMS Educator Podcast. I'm Rob Lawrence and I'm back in the studio. I was out on, as Hillary tells me, other duties as assigned, doing some stuff around the country, etc. But I was monitoring, I was watching, and I was also able to give the the Rob recap, which is that one minute you get before the show starts. And let me tell you, that's actually difficult because To try and sum up in one minute the excellence that goes on in the EMS Educator podcast is challenging. So I'm not gonna give you guys a minute. I'm gonna give you an hour right now. And to help me do that, as always, is Hilary Gates H. I'm back.
Hilary Gates: back missed you Rob so glad that you got to do the Rob recap don't ever ask me to do the Hillary hits or whatever we call them because there's no way I could talk for only a minute. Highlights highlights yeah
Rob Lawrence: Hillary's highlights, I think we're gonna call them. If if you have there we go. Yes.
Hilary Gates: perfect we are missing our good friend Maya tonight but she has other duties as assigned and that's right that's right
Rob Lawrence: it's her turn. Right, there we go. Someone has to be on other duties.
Hilary Gates: it's good that we have a few a few people got a deep bench, as they say. but I'm super pleased to have two of our really great friends in EMS with us tonight. And that's Tracy Lascar from Alaska and TJ Bishop from Washington State, more specifically the San Juan Islands, one of my favorite places. And we're gonna talk about austere frontier, rural, remote EMS and how working in those environments makes the education needs a lot different for the clinicians. And Tracy and TJ are both great experts in this field and so really happy that they're here. Tracy, will you go ahead and introduce yourself and tell us who you are, where you work, and and then we'll move over to TJ. Go ahead.
Tracey Loscar: Yeah, sure. my name is Tracy Laskar. I am the deputy director for the Matsue Borough Department of Emergency Services. I oversee the EMS department and I am in South Central Alaska, which is about one hour north of Anchorage and we cover an area that is about twenty five thousand square miles or roughly the size of West Virginia. So we are the second largest EMS department in the state and the only third service. So mm-hmm.
Hilary Gates: Thanks, Tracy. TJ?
T. J. Bishop: Hi, I'm TJ Bishop. I'm currently the interim chief administrator for San Juan Island EMS in Washington State, which is the last set of United States Islands if you go northwest of Seattle before you run into the country of Canada. I don't have as much territory to cover, but as the title implies, I literally am on an island. We are a public third service just like Matsu, and we are separate from our fire department, and we are the only third service on our island. Within our county, there are three other fire departments that also do transport, but within our island, we are it. We have a private fixed-wing air ambulance and then two rotors that come from the mainland. We cover our island and about eight smaller ones around us, and our we are what's called a public hospital district, which is really unique. And there's about six of them to Washington. And we are supported by tax levy, and we do 911 and air facility transfers from a five-bed critical access hospital here on the island.
Hilary Gates: lot of data there, TJ. it's important that people understand what it's like for you and the other islands in the archipelago in terms of facilities. There is only one hospital, it's on your island. what do the other islands do when they pick up a patient in the ambulance?
T. J. Bishop: Sure. So the two other advanced life support fire departments, one at Orcas Island where you presently are, and then one on Lopez Island, which I also work a little per diem on, they only have urgent care clinics that are open Monday through Friday, that are serviced by a couple of health organizations. They have to completely triage patients, whether being transported at all. Sometimes they go by private vehicle, sometimes they load them on the ferry to go by private vehicle. the greater majority, most of the acute ones are actually air transported off the island. they don't have any hospital. On rare, rare occasions they'll bring over here, but most of the time they go to the mainland to a more definitive care. In our island
Hilary Gates: By boat by boat or by plane or by helicopter.
T. J. Bishop: Mostly by helicopter or by plane. And then on our island, our critical access hospital basically is a level four trauma. They just recently became a level two stroke. We used to air evacuac all of our strokes off. no cardiac designation. we are blessed in the fact that it it it's a critical access hospital from a very large health system here in the Puget Sound called Peace Health, but they actually have board certified emergency medicine physicians inside their Hospital, which is pretty unique. They don't do any OB or pediatric type care for the most part and have like a five-bed step down. So we obviously, if they're lower acuity, they'll come by ground here with us. And then most of our high acuity patients are air evacued with again a helicopter or an aircraft to the mainland. rare occasions go by boat. the way we get out to our outer islands is by sheriff's boat, occasionally our local fire department. that's actually designed to take patients on it. And we will actually go off out of district when we have the staffing. We seem to be a little better staffed than some of our partners. that there are about six different islands out here in the county that don't pay taxes but still expect the level of service when something somebody gets injured or somebody's sick. So we go out and try to service those as well.
Hilary Gates: I just wanted to say all those things, Rob, because the when I spend time up here I realize that when I see anyone in fire and EMS and if I see an ambulance, very, very, very strange to me and probably to most people in EMS, knowing that the person in that ambulance is not going to a hospital. that's on the island. It's just a very odd concept. and so thanks for indulging me with with that information.
Rob Lawrence: No, not at all because actually well we're painting the picture here and getting getting
Hilary Gates: That's right.
Rob Lawrence: ready to have that sort of training and education discussion. And and which kind of brings me over to you, Tracy. The last time we spoke, by the way, in a formal interview, we were getting ready for the local volcano to blow, if you remember that. So I mean, you know, to talk about hashtag EMS issues.
Tracey Loscar: T talk about ha hashtag
Rob Lawrence: But let's talk about terms and terminology for a second before we get into the training and you know, we we heard from TJ just then about the the services that are available or are not available. You talked about the geography that you have, but these terms that we talk about, austere, rural, wilderness, frontier, can you kind of define them and work out and and then explain, you know, where you sit in that sort of spectrum of terms.
Tracey Loscar: Sure. I think it's important to remember that frontier isn't synonymous with small, right? you know, if Alaska, you know, has taught me anything, right? So as yeah, I like to lead with the size of the borough because twenty five thousand square miles sounds immense, but I only have thirteen hundred miles of road and I can only go where the road goes. Anything else requires additional resources, right? So distance is a clinical variable. Right. So is weather, communications, geography, your destination capability, right? So it's it's whether the resource you need exists at all. that's what defines frontier, right? At least to me, right? Does does the resource exist at all? whether you're talking austere versus frontier versus rural versus remote. you know, here we we actually run the gamut by both
T. J. Bishop: Yeah.
Tracey Loscar: federal definition and practical definition. I have everything from an urban swath according to population, right? All the way through off grid. You know, we have entire areas of the borough that people do live in year round that are Inaccessible to me during during large portions of the year. Right? So all that has to come into play if they have a medical need at certain points during the year. So it's very important to understand that a rural or frontier call isn't an urban call with just a longer drive, right? So
Rob Lawrence: Yep. I I was doing some work with British Columbia a while ago and they you know, if you're in Vancouver, you'll get an ambulance in nine minutes. Anywhere else we'll have a para rescue man with you within twenty four hours. It's that kind of I'm I'm
Hilary Gates: Yeah.
Rob Lawrence: imagining that kind of setup.
Tracey Loscar: Right. That's we have the military in our algorithm as well, right? So it can go anywhere from eight minutes to three to six hours, depending on school time.
Rob Lawrence: So to help us continue to set that scene then, so sort of talk
T. J. Bishop: Thanks.
Rob Lawrence: about, you know, the the call volume and you know, some of the s you know, cla injuries you you have, because not only do we have the volcano that could blow, it's really dark for a lot of the year, in addition to the distance, the geography. and so you know, what do you see? And and and it of course it's snowing. You need a snow snow snow
Hilary Gates: Yeah.
Rob Lawrence: track mobile thingamajiggy as well to get somewhere. So talk about the the calls and the challenges and the types of types of thing you're seeing before we get into how we deal with it and how we educate for it.
Tracey Loscar: the weather and the dark can be extreme, yes. there are other areas of the state that see far more extremes. It does it does complicate things if you do have to go off-road. the dark and the cold, yes, in the winter, close to mid-December. We do have about four and a half hours of daylight, you know. compared to twenty hours of of darkness. And then in summers, you know, mid summer we have the the opposite. so it can be complicated like that. but what is more would say more complicating, we have two factors. One, we have Alaskans that don't ever want to leave. So again, they're they're in these places entrenched year-round and they want to stay in place and recreation, the huge swings in recreation become a challenge because you have people who come to Alaska as bucket listers. and go to places they probably are really not well prepared for. So we're just ending our high season right now. so we'll have people out on six-wheelers or going into areas of this state that they are probably not as prepared for as they should be or have a increasing chance of running into wildlife, poor weather, unprepared, that sort of thing. Bear attacks, you know, that sort of
Rob Lawrence: My checklist is now full of volcanoes, bears, twenty hours of daylight,
Tracey Loscar: Volcano.
Rob Lawrence: probably mosquitoes more than you can handle. but
Tracey Loscar: No lava, lava. We get ash. We would get ash. Remember we talked about this.
Rob Lawrence: Of course. We had it we had a great conversation about that and actually I'll put we'll put that in the show notes as well, the article we wrote off the back of that around just some of the things that you have to consider. Hilary, do you want to pick up on the training discussion though?
Hilary Gates: Yeah,
Tracey Loscar: a
Hilary Gates: What strikes me here, of course, Tracy and TJ, is this idea of in a in a regular EMS system or one that's extremely well resourced and small in s in scale, like where I worked in Northern Virginia, our transport times were never longer than fifteen minutes and one hospital was right down the street and this was not even something I needed to consider. So we want to talk about why the transportation part is a of course a key decision as it as it is for most of us in the MS taking patients. But but really what happens when we first get to the call and as we're going to the call, and then of course what happens before that when we're training our clinicians, when you're training your clinicians how to operate in these environments. So Tracy, you wrote a wonderful article in EMS World recently called Same Stakes, Fewer Reps.
T. J. Bishop: Loved it.
Hilary Gates: And I wanted to know what prompted you to write that. What what was there an event or an occasion that you'd been thinking about or something that brought brought this up for you where you said I need to get this message out to the larger audience of EMS and and kind of talk through that concept of same stakes fewer reps.
Tracey Loscar: I think critical decision making is probably one of the hardest things to teach, right? It's how do you teach someone to make a decision? We talk about it in AMLS and other topics, is how do you make that cardinal, you know, that that cardinal decision making. And you know, coming from Newark, New Jersey, which high-volume urban system is that you come from a place where the repetition is almost invisible, right? You have the constant data. Right. And you don't realize how much that the next call is teaching you until you go to a place where the next call isn't always coming. so high volume systems acquire experience almost accidentally. Right? I would go on, I'd come I came out here and I was like going on calls and I'd be what do you mean you have never seen that before? I went to a dialysis center with an entire as a bat I came out here as a battalion chief 10 years ago, and I'd go on a call and it'd be like, What do you mean you've never seen a dialysis patient before? Or you've never seen a what I considered a mundane call before. And these were not new providers at the time, and they just hadn't, and it was not anything outrageous, right? So at some point you have to stop asking. why the provider doesn't know something and ask where the system expected them to learn it. Right? And especially if the system doesn't have it built in. Right. And in a in a volume system, right? It's data in, data out, data in, data out. So a busy system's gonna give you a patient and a pattern and a decision, an outcome and feedback, and then another patient. And you get that outcome and feedback again accidentally, because you're gonna see them, right? You're gonna see it over and over again. But a low volume system may not see that. Right? So you have a patient and a pattern and a decision. And then the patient goes into the hospital and I only have one. I'm only slightly better than TJ in that regard. Slightly. I have one. No burn center. No anything else. I mean, there's nothing between us and Fairbanks. Nothing. Right? And there's no burn center anywhere in the state. There's no level one trauma center anywhere in the state. so patient goes into the hospital, it may be six months before they see another one of that type. Right? So now I have these two crucial pieces, right? No feedback. Right? No outcome and no feedback. Right? And and nothing, you know, so the so two pieces, no decision practice or feedback. So where is the expertise building coming from? It's it's you're missing two components for to build expertise. It's not the provider's fault, it's missing from the system. Right. So that's when we're like, okay, is it truly skill erosion if they never had the ability to build the skill in the first place? Not truly, right? And Alaska's nothing if it's not ad hoc and adaptive, right? They do the best that they can. They're gonna fill in, it's like Jurassic Park. They're gonna take the frog DNA and they're gonna build it in there, right? And so and then if you look at the literature, right, the rural clinicians, they're not bad clinicians. Right? They just they don't have the information, right? It can tell if you look at the literature, it tells you where the predictable places are. It's all those things that they don't get to see except once every other year. Right? It's it's cardiopulmonary and it's that high-risk respiratory and it's you know, you know, high risk trauma, the things that they aren't gonna see. So well, you can give them certification classes. Well, there's a difference between competency and fluency. I mean I've been off the truck for a couple of years. Uncertified. Doesn't mean that I'm fluent right now, right? Current is an administrative status, right? Fluent is a performance condition. Right. So, you know, we had to go back and revisit. So, you know, you take all those pieces and put it together. If we know that, you know, the tyranny of distance and we know that you know, what defines if we know that distance is the clinical variable and time is your enemy, right? And the pieces that are missing to help them build the you know, what t what two pieces are missing from expertise. Now we go over to the neuropsych and say, Okay, well if the brain doesn't know the difference between practice and real, you know, let's build the pieces that are gonna create those performance measures over and over again. Right? So that's kind of where that started from. So
Hilary Gates: Yeah. You've clearly thought.
Tracey Loscar: that's where
Hilary Gates: Go ahead.
Tracey Loscar: Yeah. No, no, that's that's that's where that came from was how do we make this simpler because you don't want to send the message that you think a rural provider is less than, they're not less than. The system they they just need a better system. Right? You can't train them in the same system because they're not getting the same data back. Right? The same feedback loop. So
Rob Lawrence: I was just gonna jump in with a comment on that before you y you you talked to TJ Hillary, but it it's it's interesting things y you raise. I mean, I ha I can't compare my UK experience, but we were you know, the east of England was the thirty, forty minutes between hospitals. no helicopters, right? And so everybody became really good at care because I I adva fast forward to Richmond inner city, two minutes between the gunshot wound and the and the surgeon, it is very fast, very furious. But actually that level of patient care, I'm not saying it wasn't there, but actually it wasn't able to be practiced because the distance and then the the bit the need to observe that patient all the time, because you're the one person in the back of the vehicle, was ac actually made, I would argue sometimes, for a better medic. But that was just my
Hilary Gates: Yes.
Rob Lawrence: take on things.
Hilary Gates: I agree. I've heard that from s many, many people who have worked in in rural and dis you know environments that have a lot of distance and environments that don't have places to take patients to easily. there's many more refusals, there's many more creative solutions to whatever the patient's problem is, there's many more treatment in place, and and lots Lots of these practitioners have higher scopes of practice and are doing pericardiosentesis in the field or whatever it is that that is not going to happen in Richmond or or in an urban environment. Let let's talk about what that what that leap, Tracy, that you're talking about where where you say, I understand that I now need to manufacture these scenarios for my clinicians so that they're ready for the first time they see it in the field. Let's talk about that leap to the classroom and and getting them ready. And TJ, you're an educator at heart, I know, and have done a lot of work around training environments. What are some of the ways that you teach assessment and and making that complete assessment and getting to the patient and saying saying to your clinicians before they get there, what are you saying to your clinicians to think about before they get there and then when they get there? Talk us through that a little bit.
T. J. Bishop: Yeah, great question. A matter of fact, Tracy and I actually had this discussion when we saw each other last. We are comparing field training evaluation programs and onboarding. So out of the five paramedics that I have here, all but two of us, I'm a Northern Virginia community college grad. I worked in Alexandria as well. are all Harborview King County Medic One trained. and again, one of the reasons, all of Lopez paramedics are also Harborview trained. And one of the reasons that this organization historically has had them formally trained there is because of the skill exposure to get those repetitions in because what they encounter in school in the streets of Seattle is probably in a large regard, especially things like intubations and things like that, are gonna carry them for the greater part of their career. in you know, we try to send very senior EMTs to paramedic training. But one of the very first things I was charged with when I came on board here, I started as the assistant chief of operations of training four years ago, was I had an EMT class. So our department, we have one staffed medic unit with one Paramaking EMT that covers this entire island and the nine smaller ones around us on a shift rotation. but we have a complement of about 25 volunteer EMTs that actually respond private vehicle to calls or come in and staff other rigs and pole station shifts and et cetera. But I had a graduating EMT class that was just finishing when I got hired. And my chief at the time was like, Hey, I need you to come up with some type of onboarding plan for these. And he was actually one of the graduates in the EMT class. because there was a kind of a task book, but not really anything structured about how to people here for years and years as volunteer EMTs basically got their experience by simply running calls. And it, you know, I got here right at the butt end of COVID being over, where a lot of our volunteers hadn't responded like in over a year. So I had kind of a big challenge. and one of the first things I had done is established a a formal field training evaluation program, which is what T Tracy and I were talking about in D C not too long ago. how do you structure a field training program? for your system to onboard and to make you know clear people to be independent practitioners in your system that makes it work for your agency because Tracy had kind of compared notes a little bit and hers is a little bit different than mine. And mine's not as not quite the same as like some of our colleagues in King County Medic One because ironically today I had I have a paramedic that's being onboarded in field training right now that just graduated Harper V's program. Two of her classmates just came over to the island to kind of see everything. And their probationary field training experience is about it is drastically different than what my paramedics is is going through. So it was, you know, structuring a program and what does it look like? What's right look like for here? so we got, you know, I I formerly trained field training officers. we've revised the program once. I've had two paramedics go through it sent from Harborview since I came on board. And we're constantly tweaking it anywhere from scopes of practice to exposure, number of skills. And the big thing about field training versus just like a task book is like what's their behavior? Because no different than where Tracy works, we need practitioners that are not only leading their EMT partner or a group of volunteers, and even sometimes on rare occasions our fire department, but making logistical decisions because obviously when you're in environments like this, it's like 25% patient care, 40% scene management. 10% patient care, another 15% scene management, you know, and doing all the things and then realizing, this patient's not serviced here. You know, am I focusing on getting the definitive career correctly and all the things that go into that? So it's kind of a big challenge to throw somebody that's from a paramedic initial paramedic student perspective into a system that gets a lot of skills, but there are two paramedic students on a medic unit with two senior paramedics on it. So there's four paramedic ish on an ambulance. And in the streets of Seattle where the Indian Company's got four people, a medical services officer, supervisor, and sometimes a battalion chief, like in a cardiac arrest, they have like between 15 and 20 people. It would take 25 to 40 minutes for me to get that many people on a code. And then so they're in a practicing an environment where their support system, kind of like probably in Richmond, it y you can't throw a rock without hitting three or four people. Whereas here, you may be it. So we have three command officers, kind of like battalion chiefs, if you will, that respond, you know, on high acuity calls and that sort of thing. But yeah, these crews, unfortunately, my my providers and different traces have to be able to completely independently practice, with extremely good protocols, an exceptional medical program director, but be able to think on their feet and and make decisions that completely impact people. So yeah. And I do a ton of contain education here as well.
Hilary Gates: Great. Tracy, what does that look like? You talked a little bit about the neuropsych part and that's kind of what I want to get into. what's kind of some of the assessment blind spots that you see maybe in providers who come to you from a more high volume system or like yourself? what are some of the detective work pieces that you can kind of teach and and h help them notice and also bake into your scenarios. What are some of those cognitive biases that that show up? if you can be specific about
Tracey Loscar: if you make specific Well, yeah, a lot of it you learn the hard way. we struggle with it all the time, right? Because we don't get experienced people, right? They're unicorns. so we have to do a lot of interior building, right? Initially we had to revamp our hiring process, right? Because we weren't getting, you know, to ask for someone with five years experience out here is almost impossible. Right. So if you know that everyone coming through the door is going to come in with low experience from low volume rural systems, you're just working with a handicap. So we had to retool our scenario setup to look for soft skills first. Can they make ethical decisions? Can they make moral decisions? Can they so our critical fails went from protocol based to You know, can they make, you know, are they gonna be kind to the hospice patient? Are they gonna be patient with the nasty agency worker, right? Like that sort of thing. Because we can teach, we can teach the other stuff, right?
T. J. Bishop: Amen.
Tracey Loscar: so we had some success, you know, we definitely had some success with that. And then you have to build some other things in, like they do the, you know, we moved to the FTEP model, right? We brought up NEMSMA and then went to the FTEP model. For onboarding. because what what we ended up doing was my first year after I became battalion chief, I went to operations chief and we did a full-blown mass casualty event. And when we went back and did it the second year in a row, all the lessons we had learned, they had had lost. And you know, it was our first valuable lesson was the overkill wasn't working, right? Was breaking things down into the smaller pieces and learning about procedural memory and and that's what we have to keep going back to is when we see that erosion is bringing it down into micro drills and the small skills and getting them to notice because even worse than critical decision making is trying to teach situational
Rob Lawrence: Yeah.
Tracey Loscar: awareness and things like scene interpretation, right? So The thing about rural medicine, I mean, it's important in EMS regardless, whether it's situational awareness, no matter what you're talking about, but how do you teach the detective's eye? You can't that, you know, what does a complete assessment look like? It's what happens when
T. J. Bishop: What's
Tracey Loscar: the diagnostic workup, right? Your assessment, you know, isn't the prelude to the to the diagnostic workup. It is the diagnostic workup. Especially if they're not gonna get to secondary care, you know, for three to four hours. Right? So in an urban setting, you know, a one blood pressure is great, two blood pressures is ideal, right? That was a minimum for us. You know, but here, you know, one blood pressure is a photograph, three blood pressures, now you have a short film. Right?
Hilary Gates: Mm-hmm.
Tracey Loscar: Now I have now I have something to look at, right? So what do you teach them? What's present, what's not present, what's different, what's missing, how to do an interview, you know, what looks a little bit different, how to record those clues. You know, what what does what does demographic mean? You know, what does demographic really mean? You know, and when does something look out of sorts? how to how to ask. questions, how to do an actual patient interview and when those questions might look a little bit different and when they should give you cause for concern and how to build a picture out of that and not just react to an algorithm, right? Not just re if this then that. But it's it's really hard when and just manufacturing more and more repeat patterns. But building up, instead of making them go into really complex, we start we went the other way. So the scenarios they go into were like this isn't working because they weren't retaining it. And you know, you'd you'd send them into one scenario and it would take twenty five, thirty minutes just to run the scenario because you would be pulling teeth to get them to the bottom of the algorithm. So instead just put them into the low you know, the low end, put them into the shallow end of the pool, and if you could just get them to ask the first right question and pivot once, stop the scenario there, right? And and start there, right? So that it sticks. so that they would remember the cue. that's where you start, right? Clinical gestalt, I mean, it's it's compressed pattern recognition, it's not mystical. You know, it's not Harry Potter. But it's only good is
Hilary Gates: She's
Tracey Loscar: the patterns that, you know, are accumulated and the feedback that calibrates them.
Rob Lawrence: So we we were saying before we started recording here that a a lot of the sort of austere wilderness stuff can we we learnt a lot from, you know, our operations in Afghanistan over the last twenty years where, you know, the the the patient, the casualty had the platinum ten minutes, the golden hour, you know, surgery immediately and then evacuation, etcetera. And now that's being flipped on its head when we start to look at some of the medical lessons and I'm I've read these out of Ukraine, and that the pas casualty shouldn't be expected to be evacuated for twenty four hours because of the air situation, because of the drone situation, et cetera. What that means is it puts the reliance back on the medic, and it could be the combat medic, not even the paramedic, to actually look after and take care of that person for a long period of time. And I'm thinking now there's some lessons to be learned from certainly Tracy and obviously certainly TJ in terms of How do you how do people now work in these environments? And t J, you know, on on on the island, how are people coping, working and delivering with the sort of, you know, the the enemy what did Tracy say, you know, time is the enemy here. B and actually my Ukraine situation, time is definitely the enemy and people are, you know, bleeding out and and fading away, not because of the the medic, but because of the time. And so how you how you saving the patient and saving the time?
T. J. Bishop: I would have to unequivocally say we are very blessed here. our medical program director, Dr. Joshua Corsa, is a trauma surgeon in the civilian setting by trade, and he's also a trauma surgeon in the US Army Reserve, which is where we met. that's actually how I end up in this position. but he is actually available by phone. But we have some of the most progressive protocols in the United States. We do point of care ultrasound, we do finger theracostomies. We're in a study right now using H and H meters and lactate meters. yeah, we do you know, VL intubations and that sort of stuff. we're we're very blessed in the fact that like he actually comes here every single month and does case reviews of the prior cases with the paramedics specifically and then again with the EMTs. And he knows all of our providers by first name. You literally can call Dr. Corser or text him during most incidents if, you know, you're kinda wanna phone a doc or you know, the clinical decision making piece, like I don't understand this, or hey, take a look at this ultrasound, you know, scan something like that. so a lot of it has to do with a very, very comprehensive, very tight QI process. he does not hold any punches and keeps all of us very accountable. we have a pretty decent feedback loop with most of our hospitals about patient outcomes and that sort of thing. And we're starting to y you know, leverage technology a little bit. We're using Pulsera and we also use HAND TV for, you know, reducing medication errors and things like that. So we do have some things in place and we've been blessed in the fact from our CQI efforts we've been recognized by the AHA for the last four years for stimulant stroke care. We have some of the highest cardiac arrest survival in our state. but it really has to it really does start with the medical director that that holds us accountable. And again, going back to Tracy's comments, the assessment findings, the diagnostic testing, where's the right facility for you, picking up on some of those subtleties. You know, like for example, just had a crew last night, you know, had a patient with you know, a very poor clinical presentation, wasn't a clear STEMI, but EKG was certainly wasn't normal. You know, it's not black and white algorithmic medicine like this doesn't really fit the criteria to like fly this patient off to a STEMI center. However, I don't think this critical access hospital is the right place for either, because the only thing it does with patient here is it has you know, delays their care three to five hours length of stay, and then we turn around and transfer them on an IFT later, we might as well send them to definitive care and cut cut that out of the equation. so a lot of it goes, you know. into a constant feedback loop into what am I seeing, what are my diagnostics telling me, what's my clinical intuition telling me? And then those times you're like, this isn't clear cut. Hey doc, what do you think? This is what I'm thinking. He's like, Yeah, I support which is exactly what happened last night. Yeah, I I certainly, you know, can't fault you for that. Go ahead and fly them off, you know, to to Bellingham. So it's it's things like that.
Hilary Gates: Tracy, is there a call that that sticks out for you as an example of some of these things that certainly for our listeners who have not been to the great state of Alaska or been working in environments like this that would help them kind of frame the the need for the education that you're describing?
Tracey Loscar: it's defining what the resource piece that's missing, right? And how how to get them to to fit that in there, right? So it you know, just like TJ said, right, we have a really involved medical director, we have you know, how you know how we address the same thing is we expanded the scope of everything, right? So for us, what we did was we went to our system and I swear there's a point to this, right? So we went to the system and you know, from the whole time that I've been here, I ask two questions. I say, why do we do it this way? And who says, right, who says we have to do it that way? Right. And, you know, same thing, you know, we've been recognized by the AHA. We have a really involved medical director, you know, we have training built into the full-time schedule now so that they get eight hours every month. And but in Alaska we have levels of EMT. similar to AEMT but we have our EMT2s can do IVs and medications. In fact the Alaska scope for EMT2 is is is based now on our model and but we found out a year or two ago that there was an EKG model for EMT2s. So we're like well that would help even more, right? So they all back into the classroom, right? Back into the classroom and and now all of our EMTs can also do 12 leads, capture and transmit. The very first day they caught a STEMI, right? And well, I mean very like literally within hours of us saying, you know, 8 a.m. it's going live, within two hours or so one of our EMT trucks caught a STEMI. but I bring that up just a month ago, one of our EMT trucks they found a profoundly hypothermic gentleman. Up off-road in one of the very rural areas, was turned out to be a refractory V fib, very complex case, ended up on ECMO, they had to fly it out of state, flew it to Washington, very complex case. Anyway, he he lived, he walked out of the hospital, he was extubated a couple of days ago, right? But it was the EMTs. Yes, they had a medic intercept, but it was the EMTs, and because of the whole system development we did in the last few years. They were able to manage that cardiac arrest up until the point of the intercept, including the airway, including the medications, including the vascular access, which a decade ago they wouldn't have been able to do, right? And it was multiple defibrillations, and that was a result of of everything that we've built by identifying the needs and saying, what is the resource that's missing and what's our enemy? Time, distance, and geography, right? So So, you know, that's what you look at and I would say for anybody who's saying, How do we do that for our system, you know, you don't go by the case volume, identify by the risk. Where where's my risk? Identify your cliff.
Hilary Gates: Lot.
Tracey Loscar: You prepare for the cliff. Right. And yeah, so that would be the case, you know. And you you go from there, right? and you start simple, you know. in the article I talk about the hard deck, you know, you make it real simple. You say if this, then that. To use aviation, you talk about the Ukraine, how do you get them to survive? Don't make it complicated, right? If if the number is this, make this decision. You can figure out the the rest of it later on.
Hilary Gates: So as we think about what our listeners can take away here, Tracy and TJ, you've given us so many pearls. let's let's say if an educator listening wants to enact something tomorrow, or next week, especially the few important things that you've learned working in the in the position that you are. what would these things be? What would be your advice to them for the classroom or for
T. J. Bishop: Sure.
Hilary Gates: scenarios or for onboarding? TJ, we'll start with you.
T. J. Bishop: Yeah, I think a couple of things. One, anybody that knows me, is I'm a lifelong learner. I'm constantly taking training myself. And for perspective, I'm the only advanced life support instructor in our entire county, minus my medical director. So I do all of the paramedics and at the time before the hospital had RQI, I was doing every physician, nurse, and you know, tech pretty much in the hospital. But to that end, I am constantly taking training myself. I work part-time, you know, on Lopez. Just to keep my skills up, I'm I'm luckily in a position that we're so small, I think pretty similar to Tracy, that I'm on on the car cover and emails call and supervisory stuff and still doing direct patient care. one is to just keep pushing yourself forward. And probably the last thing I want to mention is find a mentor. Find another educator, somebody in this industry, you know, that that really you see attributes and examples like. I want to be just like that person, and and and learn from them.
Hilary Gates: I love that. all of us can thank our mentors. There's a couple of them on this call with me right now, in fact, for for guiding us and coaching us. So that's a really incredible piece of advice. Thanks, TJ. Tracy, what would you say to those educators listening who would like to bring this concept to the classroom and help their students?
Tracey Loscar: it's not as hard as you think. build up, right? So I would say if you wanted to walk away with something doable, identify your five rarest high consequence events and they would be unique to your system. Don't start with a curriculum. Sit down with your medical director or your your command staff and start with your risk, right? Pick your five and then Put one of them on a repeating calendar, 10 or 20 minutes with one decision, one failure point weekly or monthly. Don't wait for your skills day or your normal class stuff, right? And then make sure that you close that feedback loop. Remember, those are the last two pieces are what's missing from building the expertise in your cruise, right? What's the cue? What should have triggered it? What failed? And what do you do different next time? Right. And that's it. Resilience is in a training plan, right? You can you can build it for your crews and and competence equals confidence and that's how you're gonna get resilience in your crews and then you'll build your confidence as an educator.
Rob Lawrence: That's amazing. before I hand over to Hillary, as Hillary knows, I take copious amounts of notes from our speakers and you know, the the things that that stick that s have stuck out for me today, and here comes the Rob list, We had the distant time and geography triangle. We had the currency fluency seesaw, right? Because that's gonna be you know, y you've gotta you've gotta strike that balance sometimes. We talked about the tyranny of distance and of course understanding your geography is is again helps you define what you need in that medic. You talked about the ethics and morals situation and also the need to be that great detective because if you're out there on your own you have to be able to discern the problem and come up with a solution and there is no one else to actually support you or help you, you're it. And so I certainly got that. I got from from TJ just again, It's a different environment. You're on you are literally on the island. It's one of those training scenarios. You are on an island. You have a pro you're on the
Hilary Gates: Mm-hmm.
Rob Lawrence: island, man. there is there is the issue in itself. And so some amazing takeaways today. And everything that Tracy says to me and everything that Tracy writes is memorable and certainly you've done it again. Congratulations. those are my takeaways, Hillary. Why don't you bring us home?
Tracey Loscar: What did you bring us
Hilary Gates: Hillary's highlights. for me, the two things that stuck out the most and TJ really brought it home with this idea of finding a mentor is that Tracy and TJ both talk about doing not doing this themselves. They're not doing this from an office with the door closed, trying to fix everything. They're using the expertise of everyone around them. TJ talked about his medical director, Tracy's talking about her command staff. You certainly are gonna bring in the veterans or the other folks who have worked in the system for a long time. and understand the humility that you have coming into a job like this. So that's really impressive. The second is the use of adjunct technology and other things that you know can help fill the voids that are created by working in austere remote rural medicine. So anything that that that a computer or phone calls or technology or an app or ultrasound can do to help with your with the other things that in a system like Seattle where you have twenty five people on a cardiac arrest and you don't have that on San Juan Island, anything like that to help. clearly these these are two leaders, Rob, that have figured out that they need to advocate for their clinicians because that's the way that they're gonna bring the best patient care to their community.
Rob Lawrence: And the leaders that are that are leading within the environment the situation that they're in, right? And so sometimes these things aren't textbook. and you know, we we heard some examples of that today. So Hillary, thank you very much indeed. don't forget, please make sure that you like and subscribe. but before we go, if you are watching this live when it comes out, we're not far off EMS World Expo, everybody. And so two things I want to talk about. Thing one is Tracy and I are actually a part of the Stand and Deliver program. And so if you are a new speaker or you want to discover an America's next top X Factor EMS speaker, presenter, educator, come along and listen into the final of the the aforementioned stand and deliver. it's on the last Friday of Expo between ten and noon, and you can hear the next big speaker, the winner, gets the first slot on the next year's expo. And so if you have someone that's got the got it in them, mentor them, set them up and line them up for a future stand and deliver. So I wanted to plug that. And also importantly, from the prodigy perspective, why don't you make our big announcement, Hillary?
Hilary Gates: We are beyond thrilled to announce that Ginger Locke, our prodigy colleague, our dear dear friend, has won EMS Educator of the Year. And Tracy
T. J. Bishop: É isso que acho que é
Hilary Gates: and TJ know about Ginger and they know how much we love her and we just can't can't celebrate her enough and feel immense gratitude for being able to tap into her brain and more importantly in her heart.
Rob Lawrence: So we get the mindset minute at the start of this particular episode of the EMS Educator podcast. And Ginger doesn't listen to it until it's done. So you're listening to this now, Ginger. We love you. We'll see you soon and we'll celebrate good and proper. So that was another edition of the EMS Educator podcast. Thank you to Tracy. Thank you to TJ. Thank you to Hilary. Congratulations to Ginger. And we miss you, Maya. What more can we say? Like and subscribe. That was it. We'll see you next time. Bye for now.
Hilary Gates: back missed you Rob so glad that you got to do the Rob recap don't ever ask me to do the Hillary hits or whatever we call them because there's no way I could talk for only a minute. Highlights highlights yeah
Rob Lawrence: Hillary's highlights, I think we're gonna call them. If if you have there we go. Yes.
Hilary Gates: perfect we are missing our good friend Maya tonight but she has other duties as assigned and that's right that's right
Rob Lawrence: it's her turn. Right, there we go. Someone has to be on other duties.
Hilary Gates: it's good that we have a few a few people got a deep bench, as they say. but I'm super pleased to have two of our really great friends in EMS with us tonight. And that's Tracy Lascar from Alaska and TJ Bishop from Washington State, more specifically the San Juan Islands, one of my favorite places. And we're gonna talk about austere frontier, rural, remote EMS and how working in those environments makes the education needs a lot different for the clinicians. And Tracy and TJ are both great experts in this field and so really happy that they're here. Tracy, will you go ahead and introduce yourself and tell us who you are, where you work, and and then we'll move over to TJ. Go ahead.
Tracey Loscar: Yeah, sure. my name is Tracy Laskar. I am the deputy director for the Matsue Borough Department of Emergency Services. I oversee the EMS department and I am in South Central Alaska, which is about one hour north of Anchorage and we cover an area that is about twenty five thousand square miles or roughly the size of West Virginia. So we are the second largest EMS department in the state and the only third service. So mm-hmm.
Hilary Gates: Thanks, Tracy. TJ?
T. J. Bishop: Hi, I'm TJ Bishop. I'm currently the interim chief administrator for San Juan Island EMS in Washington State, which is the last set of United States Islands if you go northwest of Seattle before you run into the country of Canada. I don't have as much territory to cover, but as the title implies, I literally am on an island. We are a public third service just like Matsu, and we are separate from our fire department, and we are the only third service on our island. Within our county, there are three other fire departments that also do transport, but within our island, we are it. We have a private fixed-wing air ambulance and then two rotors that come from the mainland. We cover our island and about eight smaller ones around us, and our we are what's called a public hospital district, which is really unique. And there's about six of them to Washington. And we are supported by tax levy, and we do 911 and air facility transfers from a five-bed critical access hospital here on the island.
Hilary Gates: lot of data there, TJ. it's important that people understand what it's like for you and the other islands in the archipelago in terms of facilities. There is only one hospital, it's on your island. what do the other islands do when they pick up a patient in the ambulance?
T. J. Bishop: Sure. So the two other advanced life support fire departments, one at Orcas Island where you presently are, and then one on Lopez Island, which I also work a little per diem on, they only have urgent care clinics that are open Monday through Friday, that are serviced by a couple of health organizations. They have to completely triage patients, whether being transported at all. Sometimes they go by private vehicle, sometimes they load them on the ferry to go by private vehicle. the greater majority, most of the acute ones are actually air transported off the island. they don't have any hospital. On rare, rare occasions they'll bring over here, but most of the time they go to the mainland to a more definitive care. In our island
Hilary Gates: By boat by boat or by plane or by helicopter.
T. J. Bishop: Mostly by helicopter or by plane. And then on our island, our critical access hospital basically is a level four trauma. They just recently became a level two stroke. We used to air evacuac all of our strokes off. no cardiac designation. we are blessed in the fact that it it it's a critical access hospital from a very large health system here in the Puget Sound called Peace Health, but they actually have board certified emergency medicine physicians inside their Hospital, which is pretty unique. They don't do any OB or pediatric type care for the most part and have like a five-bed step down. So we obviously, if they're lower acuity, they'll come by ground here with us. And then most of our high acuity patients are air evacued with again a helicopter or an aircraft to the mainland. rare occasions go by boat. the way we get out to our outer islands is by sheriff's boat, occasionally our local fire department. that's actually designed to take patients on it. And we will actually go off out of district when we have the staffing. We seem to be a little better staffed than some of our partners. that there are about six different islands out here in the county that don't pay taxes but still expect the level of service when something somebody gets injured or somebody's sick. So we go out and try to service those as well.
Hilary Gates: I just wanted to say all those things, Rob, because the when I spend time up here I realize that when I see anyone in fire and EMS and if I see an ambulance, very, very, very strange to me and probably to most people in EMS, knowing that the person in that ambulance is not going to a hospital. that's on the island. It's just a very odd concept. and so thanks for indulging me with with that information.
Rob Lawrence: No, not at all because actually well we're painting the picture here and getting getting
Hilary Gates: That's right.
Rob Lawrence: ready to have that sort of training and education discussion. And and which kind of brings me over to you, Tracy. The last time we spoke, by the way, in a formal interview, we were getting ready for the local volcano to blow, if you remember that. So I mean, you know, to talk about hashtag EMS issues.
Tracey Loscar: T talk about ha hashtag
Rob Lawrence: But let's talk about terms and terminology for a second before we get into the training and you know, we we heard from TJ just then about the the services that are available or are not available. You talked about the geography that you have, but these terms that we talk about, austere, rural, wilderness, frontier, can you kind of define them and work out and and then explain, you know, where you sit in that sort of spectrum of terms.
Tracey Loscar: Sure. I think it's important to remember that frontier isn't synonymous with small, right? you know, if Alaska, you know, has taught me anything, right? So as yeah, I like to lead with the size of the borough because twenty five thousand square miles sounds immense, but I only have thirteen hundred miles of road and I can only go where the road goes. Anything else requires additional resources, right? So distance is a clinical variable. Right. So is weather, communications, geography, your destination capability, right? So it's it's whether the resource you need exists at all. that's what defines frontier, right? At least to me, right? Does does the resource exist at all? whether you're talking austere versus frontier versus rural versus remote. you know, here we we actually run the gamut by both
T. J. Bishop: Yeah.
Tracey Loscar: federal definition and practical definition. I have everything from an urban swath according to population, right? All the way through off grid. You know, we have entire areas of the borough that people do live in year round that are Inaccessible to me during during large portions of the year. Right? So all that has to come into play if they have a medical need at certain points during the year. So it's very important to understand that a rural or frontier call isn't an urban call with just a longer drive, right? So
Rob Lawrence: Yep. I I was doing some work with British Columbia a while ago and they you know, if you're in Vancouver, you'll get an ambulance in nine minutes. Anywhere else we'll have a para rescue man with you within twenty four hours. It's that kind of I'm I'm
Hilary Gates: Yeah.
Rob Lawrence: imagining that kind of setup.
Tracey Loscar: Right. That's we have the military in our algorithm as well, right? So it can go anywhere from eight minutes to three to six hours, depending on school time.
Rob Lawrence: So to help us continue to set that scene then, so sort of talk
T. J. Bishop: Thanks.
Rob Lawrence: about, you know, the the call volume and you know, some of the s you know, cla injuries you you have, because not only do we have the volcano that could blow, it's really dark for a lot of the year, in addition to the distance, the geography. and so you know, what do you see? And and and it of course it's snowing. You need a snow snow snow
Hilary Gates: Yeah.
Rob Lawrence: track mobile thingamajiggy as well to get somewhere. So talk about the the calls and the challenges and the types of types of thing you're seeing before we get into how we deal with it and how we educate for it.
Tracey Loscar: the weather and the dark can be extreme, yes. there are other areas of the state that see far more extremes. It does it does complicate things if you do have to go off-road. the dark and the cold, yes, in the winter, close to mid-December. We do have about four and a half hours of daylight, you know. compared to twenty hours of of darkness. And then in summers, you know, mid summer we have the the opposite. so it can be complicated like that. but what is more would say more complicating, we have two factors. One, we have Alaskans that don't ever want to leave. So again, they're they're in these places entrenched year-round and they want to stay in place and recreation, the huge swings in recreation become a challenge because you have people who come to Alaska as bucket listers. and go to places they probably are really not well prepared for. So we're just ending our high season right now. so we'll have people out on six-wheelers or going into areas of this state that they are probably not as prepared for as they should be or have a increasing chance of running into wildlife, poor weather, unprepared, that sort of thing. Bear attacks, you know, that sort of
Rob Lawrence: My checklist is now full of volcanoes, bears, twenty hours of daylight,
Tracey Loscar: Volcano.
Rob Lawrence: probably mosquitoes more than you can handle. but
Tracey Loscar: No lava, lava. We get ash. We would get ash. Remember we talked about this.
Rob Lawrence: Of course. We had it we had a great conversation about that and actually I'll put we'll put that in the show notes as well, the article we wrote off the back of that around just some of the things that you have to consider. Hilary, do you want to pick up on the training discussion though?
Hilary Gates: Yeah,
Tracey Loscar: a
Hilary Gates: What strikes me here, of course, Tracy and TJ, is this idea of in a in a regular EMS system or one that's extremely well resourced and small in s in scale, like where I worked in Northern Virginia, our transport times were never longer than fifteen minutes and one hospital was right down the street and this was not even something I needed to consider. So we want to talk about why the transportation part is a of course a key decision as it as it is for most of us in the MS taking patients. But but really what happens when we first get to the call and as we're going to the call, and then of course what happens before that when we're training our clinicians, when you're training your clinicians how to operate in these environments. So Tracy, you wrote a wonderful article in EMS World recently called Same Stakes, Fewer Reps.
T. J. Bishop: Loved it.
Hilary Gates: And I wanted to know what prompted you to write that. What what was there an event or an occasion that you'd been thinking about or something that brought brought this up for you where you said I need to get this message out to the larger audience of EMS and and kind of talk through that concept of same stakes fewer reps.
Tracey Loscar: I think critical decision making is probably one of the hardest things to teach, right? It's how do you teach someone to make a decision? We talk about it in AMLS and other topics, is how do you make that cardinal, you know, that that cardinal decision making. And you know, coming from Newark, New Jersey, which high-volume urban system is that you come from a place where the repetition is almost invisible, right? You have the constant data. Right. And you don't realize how much that the next call is teaching you until you go to a place where the next call isn't always coming. so high volume systems acquire experience almost accidentally. Right? I would go on, I'd come I came out here and I was like going on calls and I'd be what do you mean you have never seen that before? I went to a dialysis center with an entire as a bat I came out here as a battalion chief 10 years ago, and I'd go on a call and it'd be like, What do you mean you've never seen a dialysis patient before? Or you've never seen a what I considered a mundane call before. And these were not new providers at the time, and they just hadn't, and it was not anything outrageous, right? So at some point you have to stop asking. why the provider doesn't know something and ask where the system expected them to learn it. Right? And especially if the system doesn't have it built in. Right. And in a in a volume system, right? It's data in, data out, data in, data out. So a busy system's gonna give you a patient and a pattern and a decision, an outcome and feedback, and then another patient. And you get that outcome and feedback again accidentally, because you're gonna see them, right? You're gonna see it over and over again. But a low volume system may not see that. Right? So you have a patient and a pattern and a decision. And then the patient goes into the hospital and I only have one. I'm only slightly better than TJ in that regard. Slightly. I have one. No burn center. No anything else. I mean, there's nothing between us and Fairbanks. Nothing. Right? And there's no burn center anywhere in the state. There's no level one trauma center anywhere in the state. so patient goes into the hospital, it may be six months before they see another one of that type. Right? So now I have these two crucial pieces, right? No feedback. Right? No outcome and no feedback. Right? And and nothing, you know, so the so two pieces, no decision practice or feedback. So where is the expertise building coming from? It's it's you're missing two components for to build expertise. It's not the provider's fault, it's missing from the system. Right. So that's when we're like, okay, is it truly skill erosion if they never had the ability to build the skill in the first place? Not truly, right? And Alaska's nothing if it's not ad hoc and adaptive, right? They do the best that they can. They're gonna fill in, it's like Jurassic Park. They're gonna take the frog DNA and they're gonna build it in there, right? And so and then if you look at the literature, right, the rural clinicians, they're not bad clinicians. Right? They just they don't have the information, right? It can tell if you look at the literature, it tells you where the predictable places are. It's all those things that they don't get to see except once every other year. Right? It's it's cardiopulmonary and it's that high-risk respiratory and it's you know, you know, high risk trauma, the things that they aren't gonna see. So well, you can give them certification classes. Well, there's a difference between competency and fluency. I mean I've been off the truck for a couple of years. Uncertified. Doesn't mean that I'm fluent right now, right? Current is an administrative status, right? Fluent is a performance condition. Right. So, you know, we had to go back and revisit. So, you know, you take all those pieces and put it together. If we know that, you know, the tyranny of distance and we know that you know, what defines if we know that distance is the clinical variable and time is your enemy, right? And the pieces that are missing to help them build the you know, what t what two pieces are missing from expertise. Now we go over to the neuropsych and say, Okay, well if the brain doesn't know the difference between practice and real, you know, let's build the pieces that are gonna create those performance measures over and over again. Right? So that's kind of where that started from. So
Hilary Gates: Yeah. You've clearly thought.
Tracey Loscar: that's where
Hilary Gates: Go ahead.
Tracey Loscar: Yeah. No, no, that's that's that's where that came from was how do we make this simpler because you don't want to send the message that you think a rural provider is less than, they're not less than. The system they they just need a better system. Right? You can't train them in the same system because they're not getting the same data back. Right? The same feedback loop. So
Rob Lawrence: I was just gonna jump in with a comment on that before you y you you talked to TJ Hillary, but it it's it's interesting things y you raise. I mean, I ha I can't compare my UK experience, but we were you know, the east of England was the thirty, forty minutes between hospitals. no helicopters, right? And so everybody became really good at care because I I adva fast forward to Richmond inner city, two minutes between the gunshot wound and the and the surgeon, it is very fast, very furious. But actually that level of patient care, I'm not saying it wasn't there, but actually it wasn't able to be practiced because the distance and then the the bit the need to observe that patient all the time, because you're the one person in the back of the vehicle, was ac actually made, I would argue sometimes, for a better medic. But that was just my
Hilary Gates: Yes.
Rob Lawrence: take on things.
Hilary Gates: I agree. I've heard that from s many, many people who have worked in in rural and dis you know environments that have a lot of distance and environments that don't have places to take patients to easily. there's many more refusals, there's many more creative solutions to whatever the patient's problem is, there's many more treatment in place, and and lots Lots of these practitioners have higher scopes of practice and are doing pericardiosentesis in the field or whatever it is that that is not going to happen in Richmond or or in an urban environment. Let let's talk about what that what that leap, Tracy, that you're talking about where where you say, I understand that I now need to manufacture these scenarios for my clinicians so that they're ready for the first time they see it in the field. Let's talk about that leap to the classroom and and getting them ready. And TJ, you're an educator at heart, I know, and have done a lot of work around training environments. What are some of the ways that you teach assessment and and making that complete assessment and getting to the patient and saying saying to your clinicians before they get there, what are you saying to your clinicians to think about before they get there and then when they get there? Talk us through that a little bit.
T. J. Bishop: Yeah, great question. A matter of fact, Tracy and I actually had this discussion when we saw each other last. We are comparing field training evaluation programs and onboarding. So out of the five paramedics that I have here, all but two of us, I'm a Northern Virginia community college grad. I worked in Alexandria as well. are all Harborview King County Medic One trained. and again, one of the reasons, all of Lopez paramedics are also Harborview trained. And one of the reasons that this organization historically has had them formally trained there is because of the skill exposure to get those repetitions in because what they encounter in school in the streets of Seattle is probably in a large regard, especially things like intubations and things like that, are gonna carry them for the greater part of their career. in you know, we try to send very senior EMTs to paramedic training. But one of the very first things I was charged with when I came on board here, I started as the assistant chief of operations of training four years ago, was I had an EMT class. So our department, we have one staffed medic unit with one Paramaking EMT that covers this entire island and the nine smaller ones around us on a shift rotation. but we have a complement of about 25 volunteer EMTs that actually respond private vehicle to calls or come in and staff other rigs and pole station shifts and et cetera. But I had a graduating EMT class that was just finishing when I got hired. And my chief at the time was like, Hey, I need you to come up with some type of onboarding plan for these. And he was actually one of the graduates in the EMT class. because there was a kind of a task book, but not really anything structured about how to people here for years and years as volunteer EMTs basically got their experience by simply running calls. And it, you know, I got here right at the butt end of COVID being over, where a lot of our volunteers hadn't responded like in over a year. So I had kind of a big challenge. and one of the first things I had done is established a a formal field training evaluation program, which is what T Tracy and I were talking about in D C not too long ago. how do you structure a field training program? for your system to onboard and to make you know clear people to be independent practitioners in your system that makes it work for your agency because Tracy had kind of compared notes a little bit and hers is a little bit different than mine. And mine's not as not quite the same as like some of our colleagues in King County Medic One because ironically today I had I have a paramedic that's being onboarded in field training right now that just graduated Harper V's program. Two of her classmates just came over to the island to kind of see everything. And their probationary field training experience is about it is drastically different than what my paramedics is is going through. So it was, you know, structuring a program and what does it look like? What's right look like for here? so we got, you know, I I formerly trained field training officers. we've revised the program once. I've had two paramedics go through it sent from Harborview since I came on board. And we're constantly tweaking it anywhere from scopes of practice to exposure, number of skills. And the big thing about field training versus just like a task book is like what's their behavior? Because no different than where Tracy works, we need practitioners that are not only leading their EMT partner or a group of volunteers, and even sometimes on rare occasions our fire department, but making logistical decisions because obviously when you're in environments like this, it's like 25% patient care, 40% scene management. 10% patient care, another 15% scene management, you know, and doing all the things and then realizing, this patient's not serviced here. You know, am I focusing on getting the definitive career correctly and all the things that go into that? So it's kind of a big challenge to throw somebody that's from a paramedic initial paramedic student perspective into a system that gets a lot of skills, but there are two paramedic students on a medic unit with two senior paramedics on it. So there's four paramedic ish on an ambulance. And in the streets of Seattle where the Indian Company's got four people, a medical services officer, supervisor, and sometimes a battalion chief, like in a cardiac arrest, they have like between 15 and 20 people. It would take 25 to 40 minutes for me to get that many people on a code. And then so they're in a practicing an environment where their support system, kind of like probably in Richmond, it y you can't throw a rock without hitting three or four people. Whereas here, you may be it. So we have three command officers, kind of like battalion chiefs, if you will, that respond, you know, on high acuity calls and that sort of thing. But yeah, these crews, unfortunately, my my providers and different traces have to be able to completely independently practice, with extremely good protocols, an exceptional medical program director, but be able to think on their feet and and make decisions that completely impact people. So yeah. And I do a ton of contain education here as well.
Hilary Gates: Great. Tracy, what does that look like? You talked a little bit about the neuropsych part and that's kind of what I want to get into. what's kind of some of the assessment blind spots that you see maybe in providers who come to you from a more high volume system or like yourself? what are some of the detective work pieces that you can kind of teach and and h help them notice and also bake into your scenarios. What are some of those cognitive biases that that show up? if you can be specific about
Tracey Loscar: if you make specific Well, yeah, a lot of it you learn the hard way. we struggle with it all the time, right? Because we don't get experienced people, right? They're unicorns. so we have to do a lot of interior building, right? Initially we had to revamp our hiring process, right? Because we weren't getting, you know, to ask for someone with five years experience out here is almost impossible. Right. So if you know that everyone coming through the door is going to come in with low experience from low volume rural systems, you're just working with a handicap. So we had to retool our scenario setup to look for soft skills first. Can they make ethical decisions? Can they make moral decisions? Can they so our critical fails went from protocol based to You know, can they make, you know, are they gonna be kind to the hospice patient? Are they gonna be patient with the nasty agency worker, right? Like that sort of thing. Because we can teach, we can teach the other stuff, right?
T. J. Bishop: Amen.
Tracey Loscar: so we had some success, you know, we definitely had some success with that. And then you have to build some other things in, like they do the, you know, we moved to the FTEP model, right? We brought up NEMSMA and then went to the FTEP model. For onboarding. because what what we ended up doing was my first year after I became battalion chief, I went to operations chief and we did a full-blown mass casualty event. And when we went back and did it the second year in a row, all the lessons we had learned, they had had lost. And you know, it was our first valuable lesson was the overkill wasn't working, right? Was breaking things down into the smaller pieces and learning about procedural memory and and that's what we have to keep going back to is when we see that erosion is bringing it down into micro drills and the small skills and getting them to notice because even worse than critical decision making is trying to teach situational
Rob Lawrence: Yeah.
Tracey Loscar: awareness and things like scene interpretation, right? So The thing about rural medicine, I mean, it's important in EMS regardless, whether it's situational awareness, no matter what you're talking about, but how do you teach the detective's eye? You can't that, you know, what does a complete assessment look like? It's what happens when
T. J. Bishop: What's
Tracey Loscar: the diagnostic workup, right? Your assessment, you know, isn't the prelude to the to the diagnostic workup. It is the diagnostic workup. Especially if they're not gonna get to secondary care, you know, for three to four hours. Right? So in an urban setting, you know, a one blood pressure is great, two blood pressures is ideal, right? That was a minimum for us. You know, but here, you know, one blood pressure is a photograph, three blood pressures, now you have a short film. Right?
Hilary Gates: Mm-hmm.
Tracey Loscar: Now I have now I have something to look at, right? So what do you teach them? What's present, what's not present, what's different, what's missing, how to do an interview, you know, what looks a little bit different, how to record those clues. You know, what what does what does demographic mean? You know, what does demographic really mean? You know, and when does something look out of sorts? how to how to ask. questions, how to do an actual patient interview and when those questions might look a little bit different and when they should give you cause for concern and how to build a picture out of that and not just react to an algorithm, right? Not just re if this then that. But it's it's really hard when and just manufacturing more and more repeat patterns. But building up, instead of making them go into really complex, we start we went the other way. So the scenarios they go into were like this isn't working because they weren't retaining it. And you know, you'd you'd send them into one scenario and it would take twenty five, thirty minutes just to run the scenario because you would be pulling teeth to get them to the bottom of the algorithm. So instead just put them into the low you know, the low end, put them into the shallow end of the pool, and if you could just get them to ask the first right question and pivot once, stop the scenario there, right? And and start there, right? So that it sticks. so that they would remember the cue. that's where you start, right? Clinical gestalt, I mean, it's it's compressed pattern recognition, it's not mystical. You know, it's not Harry Potter. But it's only good is
Hilary Gates: She's
Tracey Loscar: the patterns that, you know, are accumulated and the feedback that calibrates them.
Rob Lawrence: So we we were saying before we started recording here that a a lot of the sort of austere wilderness stuff can we we learnt a lot from, you know, our operations in Afghanistan over the last twenty years where, you know, the the the patient, the casualty had the platinum ten minutes, the golden hour, you know, surgery immediately and then evacuation, etcetera. And now that's being flipped on its head when we start to look at some of the medical lessons and I'm I've read these out of Ukraine, and that the pas casualty shouldn't be expected to be evacuated for twenty four hours because of the air situation, because of the drone situation, et cetera. What that means is it puts the reliance back on the medic, and it could be the combat medic, not even the paramedic, to actually look after and take care of that person for a long period of time. And I'm thinking now there's some lessons to be learned from certainly Tracy and obviously certainly TJ in terms of How do you how do people now work in these environments? And t J, you know, on on on the island, how are people coping, working and delivering with the sort of, you know, the the enemy what did Tracy say, you know, time is the enemy here. B and actually my Ukraine situation, time is definitely the enemy and people are, you know, bleeding out and and fading away, not because of the the medic, but because of the time. And so how you how you saving the patient and saving the time?
T. J. Bishop: I would have to unequivocally say we are very blessed here. our medical program director, Dr. Joshua Corsa, is a trauma surgeon in the civilian setting by trade, and he's also a trauma surgeon in the US Army Reserve, which is where we met. that's actually how I end up in this position. but he is actually available by phone. But we have some of the most progressive protocols in the United States. We do point of care ultrasound, we do finger theracostomies. We're in a study right now using H and H meters and lactate meters. yeah, we do you know, VL intubations and that sort of stuff. we're we're very blessed in the fact that like he actually comes here every single month and does case reviews of the prior cases with the paramedics specifically and then again with the EMTs. And he knows all of our providers by first name. You literally can call Dr. Corser or text him during most incidents if, you know, you're kinda wanna phone a doc or you know, the clinical decision making piece, like I don't understand this, or hey, take a look at this ultrasound, you know, scan something like that. so a lot of it has to do with a very, very comprehensive, very tight QI process. he does not hold any punches and keeps all of us very accountable. we have a pretty decent feedback loop with most of our hospitals about patient outcomes and that sort of thing. And we're starting to y you know, leverage technology a little bit. We're using Pulsera and we also use HAND TV for, you know, reducing medication errors and things like that. So we do have some things in place and we've been blessed in the fact from our CQI efforts we've been recognized by the AHA for the last four years for stimulant stroke care. We have some of the highest cardiac arrest survival in our state. but it really has to it really does start with the medical director that that holds us accountable. And again, going back to Tracy's comments, the assessment findings, the diagnostic testing, where's the right facility for you, picking up on some of those subtleties. You know, like for example, just had a crew last night, you know, had a patient with you know, a very poor clinical presentation, wasn't a clear STEMI, but EKG was certainly wasn't normal. You know, it's not black and white algorithmic medicine like this doesn't really fit the criteria to like fly this patient off to a STEMI center. However, I don't think this critical access hospital is the right place for either, because the only thing it does with patient here is it has you know, delays their care three to five hours length of stay, and then we turn around and transfer them on an IFT later, we might as well send them to definitive care and cut cut that out of the equation. so a lot of it goes, you know. into a constant feedback loop into what am I seeing, what are my diagnostics telling me, what's my clinical intuition telling me? And then those times you're like, this isn't clear cut. Hey doc, what do you think? This is what I'm thinking. He's like, Yeah, I support which is exactly what happened last night. Yeah, I I certainly, you know, can't fault you for that. Go ahead and fly them off, you know, to to Bellingham. So it's it's things like that.
Hilary Gates: Tracy, is there a call that that sticks out for you as an example of some of these things that certainly for our listeners who have not been to the great state of Alaska or been working in environments like this that would help them kind of frame the the need for the education that you're describing?
Tracey Loscar: it's defining what the resource piece that's missing, right? And how how to get them to to fit that in there, right? So it you know, just like TJ said, right, we have a really involved medical director, we have you know, how you know how we address the same thing is we expanded the scope of everything, right? So for us, what we did was we went to our system and I swear there's a point to this, right? So we went to the system and you know, from the whole time that I've been here, I ask two questions. I say, why do we do it this way? And who says, right, who says we have to do it that way? Right. And, you know, same thing, you know, we've been recognized by the AHA. We have a really involved medical director, you know, we have training built into the full-time schedule now so that they get eight hours every month. And but in Alaska we have levels of EMT. similar to AEMT but we have our EMT2s can do IVs and medications. In fact the Alaska scope for EMT2 is is is based now on our model and but we found out a year or two ago that there was an EKG model for EMT2s. So we're like well that would help even more, right? So they all back into the classroom, right? Back into the classroom and and now all of our EMTs can also do 12 leads, capture and transmit. The very first day they caught a STEMI, right? And well, I mean very like literally within hours of us saying, you know, 8 a.m. it's going live, within two hours or so one of our EMT trucks caught a STEMI. but I bring that up just a month ago, one of our EMT trucks they found a profoundly hypothermic gentleman. Up off-road in one of the very rural areas, was turned out to be a refractory V fib, very complex case, ended up on ECMO, they had to fly it out of state, flew it to Washington, very complex case. Anyway, he he lived, he walked out of the hospital, he was extubated a couple of days ago, right? But it was the EMTs. Yes, they had a medic intercept, but it was the EMTs, and because of the whole system development we did in the last few years. They were able to manage that cardiac arrest up until the point of the intercept, including the airway, including the medications, including the vascular access, which a decade ago they wouldn't have been able to do, right? And it was multiple defibrillations, and that was a result of of everything that we've built by identifying the needs and saying, what is the resource that's missing and what's our enemy? Time, distance, and geography, right? So So, you know, that's what you look at and I would say for anybody who's saying, How do we do that for our system, you know, you don't go by the case volume, identify by the risk. Where where's my risk? Identify your cliff.
Hilary Gates: Lot.
Tracey Loscar: You prepare for the cliff. Right. And yeah, so that would be the case, you know. And you you go from there, right? and you start simple, you know. in the article I talk about the hard deck, you know, you make it real simple. You say if this, then that. To use aviation, you talk about the Ukraine, how do you get them to survive? Don't make it complicated, right? If if the number is this, make this decision. You can figure out the the rest of it later on.
Hilary Gates: So as we think about what our listeners can take away here, Tracy and TJ, you've given us so many pearls. let's let's say if an educator listening wants to enact something tomorrow, or next week, especially the few important things that you've learned working in the in the position that you are. what would these things be? What would be your advice to them for the classroom or for
T. J. Bishop: Sure.
Hilary Gates: scenarios or for onboarding? TJ, we'll start with you.
T. J. Bishop: Yeah, I think a couple of things. One, anybody that knows me, is I'm a lifelong learner. I'm constantly taking training myself. And for perspective, I'm the only advanced life support instructor in our entire county, minus my medical director. So I do all of the paramedics and at the time before the hospital had RQI, I was doing every physician, nurse, and you know, tech pretty much in the hospital. But to that end, I am constantly taking training myself. I work part-time, you know, on Lopez. Just to keep my skills up, I'm I'm luckily in a position that we're so small, I think pretty similar to Tracy, that I'm on on the car cover and emails call and supervisory stuff and still doing direct patient care. one is to just keep pushing yourself forward. And probably the last thing I want to mention is find a mentor. Find another educator, somebody in this industry, you know, that that really you see attributes and examples like. I want to be just like that person, and and and learn from them.
Hilary Gates: I love that. all of us can thank our mentors. There's a couple of them on this call with me right now, in fact, for for guiding us and coaching us. So that's a really incredible piece of advice. Thanks, TJ. Tracy, what would you say to those educators listening who would like to bring this concept to the classroom and help their students?
Tracey Loscar: it's not as hard as you think. build up, right? So I would say if you wanted to walk away with something doable, identify your five rarest high consequence events and they would be unique to your system. Don't start with a curriculum. Sit down with your medical director or your your command staff and start with your risk, right? Pick your five and then Put one of them on a repeating calendar, 10 or 20 minutes with one decision, one failure point weekly or monthly. Don't wait for your skills day or your normal class stuff, right? And then make sure that you close that feedback loop. Remember, those are the last two pieces are what's missing from building the expertise in your cruise, right? What's the cue? What should have triggered it? What failed? And what do you do different next time? Right. And that's it. Resilience is in a training plan, right? You can you can build it for your crews and and competence equals confidence and that's how you're gonna get resilience in your crews and then you'll build your confidence as an educator.
Rob Lawrence: That's amazing. before I hand over to Hillary, as Hillary knows, I take copious amounts of notes from our speakers and you know, the the things that that stick that s have stuck out for me today, and here comes the Rob list, We had the distant time and geography triangle. We had the currency fluency seesaw, right? Because that's gonna be you know, y you've gotta you've gotta strike that balance sometimes. We talked about the tyranny of distance and of course understanding your geography is is again helps you define what you need in that medic. You talked about the ethics and morals situation and also the need to be that great detective because if you're out there on your own you have to be able to discern the problem and come up with a solution and there is no one else to actually support you or help you, you're it. And so I certainly got that. I got from from TJ just again, It's a different environment. You're on you are literally on the island. It's one of those training scenarios. You are on an island. You have a pro you're on the
Hilary Gates: Mm-hmm.
Rob Lawrence: island, man. there is there is the issue in itself. And so some amazing takeaways today. And everything that Tracy says to me and everything that Tracy writes is memorable and certainly you've done it again. Congratulations. those are my takeaways, Hillary. Why don't you bring us home?
Tracey Loscar: What did you bring us
Hilary Gates: Hillary's highlights. for me, the two things that stuck out the most and TJ really brought it home with this idea of finding a mentor is that Tracy and TJ both talk about doing not doing this themselves. They're not doing this from an office with the door closed, trying to fix everything. They're using the expertise of everyone around them. TJ talked about his medical director, Tracy's talking about her command staff. You certainly are gonna bring in the veterans or the other folks who have worked in the system for a long time. and understand the humility that you have coming into a job like this. So that's really impressive. The second is the use of adjunct technology and other things that you know can help fill the voids that are created by working in austere remote rural medicine. So anything that that that a computer or phone calls or technology or an app or ultrasound can do to help with your with the other things that in a system like Seattle where you have twenty five people on a cardiac arrest and you don't have that on San Juan Island, anything like that to help. clearly these these are two leaders, Rob, that have figured out that they need to advocate for their clinicians because that's the way that they're gonna bring the best patient care to their community.
Rob Lawrence: And the leaders that are that are leading within the environment the situation that they're in, right? And so sometimes these things aren't textbook. and you know, we we heard some examples of that today. So Hillary, thank you very much indeed. don't forget, please make sure that you like and subscribe. but before we go, if you are watching this live when it comes out, we're not far off EMS World Expo, everybody. And so two things I want to talk about. Thing one is Tracy and I are actually a part of the Stand and Deliver program. And so if you are a new speaker or you want to discover an America's next top X Factor EMS speaker, presenter, educator, come along and listen into the final of the the aforementioned stand and deliver. it's on the last Friday of Expo between ten and noon, and you can hear the next big speaker, the winner, gets the first slot on the next year's expo. And so if you have someone that's got the got it in them, mentor them, set them up and line them up for a future stand and deliver. So I wanted to plug that. And also importantly, from the prodigy perspective, why don't you make our big announcement, Hillary?
Hilary Gates: We are beyond thrilled to announce that Ginger Locke, our prodigy colleague, our dear dear friend, has won EMS Educator of the Year. And Tracy
T. J. Bishop: É isso que acho que é
Hilary Gates: and TJ know about Ginger and they know how much we love her and we just can't can't celebrate her enough and feel immense gratitude for being able to tap into her brain and more importantly in her heart.
Rob Lawrence: So we get the mindset minute at the start of this particular episode of the EMS Educator podcast. And Ginger doesn't listen to it until it's done. So you're listening to this now, Ginger. We love you. We'll see you soon and we'll celebrate good and proper. So that was another edition of the EMS Educator podcast. Thank you to Tracy. Thank you to TJ. Thank you to Hilary. Congratulations to Ginger. And we miss you, Maya. What more can we say? Like and subscribe. That was it. We'll see you next time. Bye for now.
