Assembly Line

 Many years ago, I worked on assembly lines in factories. I put together and or packaged everything from Christmas Tree stands and door knobs to fast food store deli sandwiches and grocery store beef ribs.

The key to the assembly line was to go a little bit faster than you were comfortable going.  You had to work hard and pay attention to keep up. If the line went too slow you were not as productive as you could be, or if it went too fast and people couldn't keep up the line fell apart and everybody had to stop and start all over at a loss of time and production.

At one of the hardware plants I worked at there were two competing inspectors. The time keeper studied your movements and taught you how to be move faster and more efficiently so more could be produced. At the other end was the quality guy and he got pissed if things were not put together right. The time keeper and the quality guy had different bosses and they hated each other. The foreman didn't care for either.  She just wanted to get the product out in as much volume and quality as possible. I was just a worker bee, paid by the hour, with the pay check coming every Friday as long as I decided to keep coming to work. I would listen to the time keeper and nod and do what he said, and then the quality guy would yell at me, and I would nod and do what he said, and then the time guy would yell at me, and then the time guy and quality guy would yell at each other and I would go back to working, trying to find my own balance between speed and quality.

The best example of this was packaging doorknobs.  They would lay a big thick cardboard sheet on the line.  On the sheet was the backing for thirty-two door knob packages. I had a big bin full of door knobs and I would try to lay them down as neatly as possible, while another guy laid down the package of screws that went with the knob.  There were several of us doing the same thing. The sheet would whip by and we would furiously lay the knobs and screws down. The sheet would go into a machine to get plastic wrapped, and then another machine -- the cutter-- cut and separated the sheet into 32 individual packages, which were then quickly hand packed into boxes of eight knobs each. If the knobs were not laid directly in the center of their package. the wrapper would wrap them and then they would get cut off-center and be unusable, provoking the quality guys anger.

What is the point of all this?  It reminds me of health care today. Whether EMS or hospital setting, there is the clash between time and quality and the two task masters aren't always working for the same person.  A friend of mine worked as a PA for a hospital walk-in clinic.  She was a great PA, a former paramedic with a great medical mind, but when her annual review came up, the only issue that mattered was coding and the number of patients she saw per hour.  On the ambulance, the conflict is often between dispatch who needs to get the calls off their board in the quickest amount of time and get cars to clear as fast as possible and the quality people who want to get the appropriate car to the appropriate call (i.e. paramedic to priority one, BLS to transfer or priority 2), and the documentation people who want to have the run forms fully documented, and all the billing collected and signatures obtained. The road people do their best to walk the line to please everyone, while not forgetting about the patients needs, not just the patient they have, but the holding 911s who don't yet have car assigned to respond to them.

I do not mean to point the finger at anyone here, just to say, not that everyone hasn't already noticed, but the health care dollar is getting stretched thin these days. ED staffs are overworked too. There is a huge turnover in our EDs due to burnout as nurses cat handle the loads they are being asked to shoulder.  And for EMS, while I love my job, I come home after 12 hours of nonstop calls and driving and want nothing more than to get in bed so I will at least be partially rested for the next days work. Even when I was a young man three 12-14 hour shifts on consecutive days wore me down and it is much busier now and I am much older.

I was listening to a medical podcast the other day, and I heard a doctor tell a group of younger doctors that while she recognized the need to face the computer and input everything the patient was saying, it was particularly important -- at least on the first patient visit -- to observe the person as they spoke to get a sense of their body language, and to better understand the meaning of their responses.  At least on the first visit!

I start writing my run forms on the way to the call.  I can fill in a lot, but  often when I am working with a new person (I have partner du jour these days as one of my regular partners has been out hurt), I can look up and see we have gone past our turn.  I screw up often in this manner, forgetting they do not all know the streets as I do.  I continue writing the form on the way to the hospital, hopefully finishing in triage so I can quickly print it, and be available for the next call. I find I chat less with the patients than I used to in the days when I could scrawl out a paper run form in a few minutes.  I am just like the doctor sometimes, looking at the computer and missing the body language.

Let me tell you a story.  I tech most every call because I cant stand to wait at the hospital while my new partners take an hour to write their run forms. But on this call, we are driving by a homeless shelter and notorious intersection for drunks. We are hailed down by a cop. She's been drinking, the cop says, and points to a twenty-five year old or so woman with dirty blonde hair, torn jeans and a scowl on her face who is motherfucking him and us both. Such a stream of cuss words. My poor ears. We finally talk her into getting on our stretcher on the enticement she can get something good to eat at the hospital.  The diced peaches are particularly good!

l do this one, my partner says.  I have already done seven calls, and it is after all just a drunk and we are a half mile from the hospital, so I let him tech.  I get in the front, and hand him back the computer, and then in the rear view mirror I see him open it up and start typing away.  I drive to the hospital and when we pull the patient out, she appears to not only be unconscious, but have agonal respirations.  I see the fresh needle marks on her arm now, and note the pinpoint pupils.  I look at my partner and am thinking “Dude, did you not noticethe change in her condition?

Hmm, he said.I bet shes on heroin.

I stimulate her with a light medium punch in the arm She opens her eyes, and motherfucks me again.  She is breathing well enough now that narcan is not indicated. I had for a moment thought of putting her and the stretcher back in the ambulance and giving her some of the intranasal stuff.  Instead we wheel her in, and oh, look, there is a line at triage. We do some vitals in there, and she is Sating at 95%. Every now and then, her respiratory rate drops and I have to nudge her again. he wait continues. More and harder nudging are required.  Eventually, not even the nudging works.  Her SAT is in the 80s now and her respiratory rate is less than 6 even with sternal runs.  She is no longer arousable.  I have to get the triage nurses attention, and borrow an ambu bag.  I should have just had my partner go back out to the truck and get my gear.

Anyway, bottom line -- no harm was done with this call, but it shows what can happen when you are looking at the keyboard and not the patient. I like to think I do a good job of typing, chatting and looking back and forth between the patient and my keyboard. I like to think I am a good employee and can find the proper balance between getting my forms done quickly and clearing the hospital and giving the patients what they need.  But I do lament that it is not like it was when I started, when I had long conversations with patients on each transport, when all my assessments were thorough, when I saw more than I do now.

I would like more of an acknowledgement from our health care leaders of the stresses the new systems place on individual practitioners who must balance the need for high volume, high-level care, full documentation and patient-provider rapport (the heart of the best health care,) while often reporting to different taskmasters for each.

I recognize if the assembly line of health care goes too slowly, it is costly and unproductive. I also recognize if it goes too fast, it all falls apart.  I will do my best to continue to try to keep pace, but the entire system bears watching. When in doubt, the only boss to listen to is yourself, doing what is right for that patient right in front of you. We can blame, often with good cause, the system, but an imperfect system does not relieve of us individual responsibility. If asked to choose between the timekeeper and the quality guy, go with the quality guy.