Taking a page from firefighting to fix health care

Taking a page from firefighting to fix health care

In firefighting, pump physics is one of the most critical things an engine company officer must understand.  How do we “get the wet stuff on the red stuff” in sufficient quantity without sacrificing penetrating power? The inverse ratio between volume and pressure (as the water pressure increases, volume decreases) has befuddled many a rookie lieutenant.

The same, I think, is now true in health care, by virtue of numbers alone. If we equate the fire officer’s “volume” with the medical practitioner’s “presence” (as in patients seen per hour) and “pressure” with the sum total of medical knowledge and capability, the analogy becomes more apropos, the similarities more apparent.  Since failure is not an option in medicine or firefighting, let’s examine how the fire service has solved this conundrum and determine whether health care might do likewise.

In the fire service, the problem has been successfully addressed with something called the changeover valve.  To understand how this works, we must first examine the terms “series” and “parallel.”  Most large pumps have two sets of impellers (pinwheel gears) that either work together in a series, with impeller #1 pushing water into impeller #2 to produce high pressure, or spin separately to produce less pressure but more total volume.

Still there? OK, just a few more terms: static pressure (water main baseline), nozzle pressure (tip of the nozzle), residual pressure (what’s left when we subtract nozzle pressure from static pressure).  Now, on with the show.

The fire officer takes a quick look at static pressure when the engine is hooked-up to a hydrant with a supply line.  The changeover valve is pre-set to “pressure.” When the first fire attack line is charged and the nozzle opened, a large gauge on the pump panel indicates residual pressure, then does the same with each additional attack line. When residual pressure drops to less than half of static pressure, the officer, or the engineer, operates the changeover valve moving the pump vanes into a “volume” setting.  In some fire departments, this is done routinely after the third attack line has been established, regardless of the various pressure readings.

So there it is.  “What?” you ask.  “The answer,” I reply.  Health care desperately needs some sort of changeover valve.  Some standard way to reduce pressure when it becomes necessary to increase volume.  It might be as simple as a standardized patient rating system with regard to degree of difficulty, although that in itself could be a challenge initially.

Also needed: Agreed-upon standard operating procedures.  And these should be written by practicing health care providers.

Here’s a final, important note: fire pumps, and the firefighters who use them, are protected from extreme pump pressures by something called a pressure relief valve. Health care should have one as well.

Rob Burnside is a retired firefighter and paramedic.

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  • Rob Burnside

    When I wrote this post, I left a few things out deliberately. One of those things is the term “discharge pressure.” This is a reading from the attack side of the fire pump, shown by a large gauge (called a “compound gauge”) on the pump panel, and is controlled by a hand throttle increasing or decreasing engine R.P.M.s as required. Pressure in each attack line is shown on the line’s smaller gauge, and is controlled by the engineer adjusting the line’s dedicated gate valve. If an attack line is shut down without warning by firefighters on the nozzle end, a sudden release of additional pressure and resultant “water hammer” is counteracted (dumped) by the pump’s pressure relief valve. Otherwise, firefighters on the other attack lines might be knocked off their feet, ladders, roofs, whatever, and the pump harmed.
    My point in all of this is conservation of resources and maximum effective utilization can co-exist The most expensive item in the whole shebang–the pump itself–is well-protected while the firefighters are provided with sufficient water plus the autonomy (and ability) to make individual adjustments as needed within a framework of accepted practices. A good, balanced system!

  • SteveCaley

    Fluid dynamics rock. Even though I’m not a cardiologist, I think that Reynolds numbers and viscosity are cool things to study in circulatory medicine.
    I think you might be over-physics’ing the thing, and under humanizing it. I talk about firefighters a lot with staffing and salary demands.
    From a sheer wild guess, I figure that about 30% of firefighters on duty at any time are actually working outside of the station. By definition, the rest of them are working on “B-list” items – stuff that can be dropped in an emergency (e.g. shining brass.)
    Well, iff 30% of firefighters at any given time are working on A-list priority stuff, and 70% on B-list stuff, let’s just fire half of them – that should work, maybe? And hire some flunky to shine the brass.
    It works great. Until multiple alarms are called in.
    It’s the same with medicine (See the IOM report on errors in 1999). During normal volume, there used to be more redundancy – which has carefully been shaved away at, and “intermediate levels” are shining the brass.
    A lot cheaper.
    Until the Big Fire hits.

    • Rob Burnside

      Another grand slam, though I think your 30% figure may be high. I can well remember people driving by the fire station yelling “Get a job!” but I doubt that’s happening much anymore after 9-11. At various points throughout my career, we were sitting ducks for administrators who really didn’t understand the nature of the work. We weren’t, they reasoned, all fighting fires eight hours a day, so some of us might not be that necessary. Of course, no one can do this job the way it must be done for more than two or three hours at a clip, let alone eight. The “redundancy” was our back-up, our safety margin, and it’s simply not there in most contemporary small city fire departments, and even many of the larger departments. And that’s all supposed to be okay until, as you say, the alarm goes off. Medicine’s worse, I think. It’s either full-tilt boogie or double full-tilt boogie. There’s no rest, and that can’t be good for anyone.

      • SteveCaley

        In fact, the oft-quoted IOM study from 1999 “To Err Is Human,” pointed out the necessity for more redundancy in hospitals, especially more experienced nursing staff. The response by the bureaucrats was to cut staffing massively, to where it is much more unsafe today being hospitalized. Instead of understanding the report, the figure of “umpteen-thousand avoidable deaths” was plucked out of it and splashed around in the press without any sense of understanding; and is used to justify all manner of idiocy in the regulating of medicine.
        After I posted my little piece above and elsewhere, I became concerned. In the Cult of Mediocrity which has seized this country, satire becomes dangerous, as today’s satire can wind up as next week’s operating instructions.
        There is a massive war fueled by jealousy between the Professionals and the Can’t-Do’s. Firefighting is one of the last of the professions surviving, and I am sure that it is equally beleaguered by the Toads of Mediocrity. Initiative, independence, experience and most of all ABILITY are the elements which make a good doctor and a good firefighter. The “redundancy” at the fire station, as a bureaucrat might see it, is statistically necessary – CRITICALLY so – to run an intelligent firefighting operation.
        If we still believed in professionalism, we could look at a Fire Department, and hear experienced personnel say, “This is the way it must be. Do you want the job done, or not?”
        Sadly, in waning and declining cultures, the job, very often, doesn’t get done – but the bureaucrat gets his way. The Empire of the Oblivious, the Kingdom of Mediocrity collapses under its own weight. I wish it wasn’t US doing that.

        • Rob Burnside

          Interesting. I’ve long called it, “The Conspiracy of Mediocrity” because it often seems deliberate, and sinister, like something out of Orwell. Citizen, why settle for “good” when, with a little extra effort, we can be truly mediocre?

          • SteveCaley

            There are a few who have used the phrase – Michael W. Hirschorn in the Harvard Crimson, and Dr. G.A. Fava in Italy. Societies see what is normal, i.e. most closely resembling the center of the average, and pretend that it is normative, i.e. a conformist manner of being most desirable within the society.

            I hope to slowly steal back the word “heteronormative” from its current use to its deeper philological meaning which would be – DIFFERENCE is the essential characteristic of people. Hetero means difference, and variability; it is only recently that through the word “heterosexual” that is has anything to say about gender preference. Normative is, of course, the social message of belongingness.

            Our society measures people only by virtue of their labels. Entrance to medical school pretends that it is done by individual scrutiny of the candidates, but actually it is nothing of the sort. What we hold as spectacular is how tightly a candidate can conform to the Rules. Usually, a Spectacular Candidate has an unthreatening incidental, e.g. “Did you know she placed eighth in the world in the Women’s High Jump in the 2012 Olympics?”

            Those sort of things are cocktail-party desirables for a new physician. “Did you know that she sued her undergraduate institution for gender discrimination and won in court?” is hardly so charming over an evening’s sherry with the alumni.

            People burrowing into conformity do not look around for things that might be unjust. The great American formula is Conformity + Patience = Success, and freethinkers who doubt the justice of such beliefs are treated like the Albigensians (i.e. burned at the stake).

          • DeceasedMD1

            Brilliant thread to you and Rob (nice article Rob!). Speaking of Albigensians, I viewed the Tyndale bible on display at the Huntington. Tyndale was burned at the stake for translating the bible into English during the 1500′s. I think we are going back to medieval times frankly. Clearly medicine and society in general is threatened by freethinkers. It is under the guise that google and silicon valley start ups are freethinkers, but if you look at their apps, as you have pointed out, aye there’s the rub.
            What is your website address if I may ask?

          • SteveCaley

            I’m at http://steveofcaley.wordpress.com/ and drop on by for a visit. Got some good Western pictures there of our Southwest landscape.

          • Rob Burnside

            Well-put, and clearly, when we think back, there have been many periods in the history of Western thought when a lack of conformity has been severely constrained, even punished with the proverbial hemlock–or worse! I’m afraid we’re in one of those periods now, and I’m at a loss to explain it other than this: it seems to be a product of fear, a reaction to some sort of external threat, actual or perceived. The threat is eventually internalized and often taken to an extreme, and then we’re at a juncture delineated by the late, oft-quoted cartoonist Walt Kelly: “We have met the enemy and he is us.” Possibly, societal fear generated by our more recent pandemics has contributed to the captivity of medical thought, when what we really need is the opposite.

          • DeceasedMD1

            Great post Rob. I did not know you were a retired firefighter and paramedic. But what a great analogy. You must have a lot of stories to tell.
            I never really thought about the issue of conformity applying to current times but it is much more pervasive than I realized. Current medicine is headed toward guidelines taking over with NP’s following the dogma. EMR’s under the guise of collaborating have destroyed the medical record. So in essence everyone looks the same. There is no uniqueness to the pt when you see the record. Previously every evaluation explained the medical problem in a unique way and the treatment plan in such a way that one could follow very clearly the thought processes but that has been destroyed. And I think now this was no accident. It is not obvios perhaps to most people but it is really attacking the cognitive processes in medicine and attacking the pt as a whole to conform. On EMR’s everyone looks exactly the same–pretty much. Love the Walt Kelly quote. Sometimes it takes a joke to get people’s attention to see their own part in this. It just seems like we live under the guise of being progressive. We have the most sophisticated technology. But underneath people will never change especially where it comes to power.

          • Rob Burnside

            Seems everything’s being reduced to 1s and 0s !
            Now, at least, I can forgive my PCP for appearing to forget, momentarily, who I am apart from my height, weight, LDL and BP.

            Thanks, too, for the fine compliment Dr. D. I might have attempted a full-time career in health care, but firefighting–even then–was less dangerous.
            I do have some good yarns. Sometime, let me tell you about the narcoleptic fire captain who fell fast asleep during an alarm response. Now that was truly frightening!

          • DeceasedMD1

            Now that’s funny! Firefighting less dangerous than HC. Probably true. Now the narcoleptic fire captain. I have not heard that one before. Sounds like a joke if it were not so deadly serious.

          • Rob Burnside

            His nickname was “Duck” and he was one of a number of older men who were allowed to stay on past normal retirement, but rumor had it he could still do the job. In any case, he was a captain, and responsible for giving directions, condition reports, and supervising a crew of five until the battalion chief arrived on-scene.

            Early in my career, I was sent to fill in as his driver for one shift. The alarm went off, Duck shouted the route as he climbed into the cab, and away we went, siren blaring. A few block later–we had a “worker”! But no condition report. I glanced over at Duck and sure enough, he was sound asleep, chin on chest and mike in hand. ” DUCK! WAKE UP!” I yelled.

            He startled, sputtered a bit, keyed the mike and gave it his best. Then he climbed down from the cab, donned his SCBA mask and tank, grabbed an attack line, and almost put the fire out by himself. Amazing! That was over thirty years ago, and I alone am escaped to tell you I can laugh about it now, and I hope you can, too. I do miss those good old days, in HC and in firefighting. We have our memories, don’t we?

          • DeceasedMD1

            wow that is quite a story. Glad things turned out. I had an attending with narcolepsy but he just fell asleep at lectures. Not so dangerous. I am guessing Duck retired after that.

          • Rob Burnside

            He did, but not right away. A year or two later, he retired standing up in his early seventies. He’s been a departmental legend ever since. I never mentioned the incident described above. We took care of our own (no exceptions) because we had to–our lives depended on it.

          • Rob Burnside

            As Skinnerian as it sounds, I sometimes think birth order has great influence over who conforms and who doesn’t, and I’d really love to know what percentage of our legendary non-conformists are first, last, and middle-born. I’d also like to know more about the variation, “normalcy.” It’s nearly archaic now and, thanks to President Harding,
            has a rather negative implication. Apparently, he campaigned on the promise of a return to life the way it was before World War I. Of course, there is no going back, and never has been. The key, I think, is how we go forward–fearfully or better yet fearlessly, as our brief history demands.

  • SteveCaley

    I rolled with the parody – I’ll extend it on my blog.

    The Fire Problem in the United States is out of control. Costs of
    firefighting have skyrocketed. A once volunteer operation, fire
    departments are now heavily staffed with full-time career firefighters,
    who are generously paid and reap massive benefits and are protected by unions.

    American firefighters have taken home trillions of dollars in
    salary – yet fires still occur daily in every town in the United
    States. The fire companies are organized in a variable pattern, each
    State, city and township adding its own peculiar structure to firefighting
    operations.

    There are no Standard Best Firefighting Practices being
    used, and there is no national certification of American Firefighters.
    No ongoing method is being used to assure that firefighters are keeping
    up with the complex and ever-developing world of Fire Science and
    Firefighting Technology. Yet, fire department remain mired in the
    pre-technology past, with little interreliance on modern methods of
    information science in the firefighting world.
    In any fire department in any major city, few Firepersons are actually
    fighting fires at any given time. Most are standing around doing
    make-work projects that are dropped when an alarm comes in. No attempt has been made to categorize the efficiency of firefighting on a National level.
    There is little ground-level documentation of the type, nature, scope and
    purposes of individual firefighter’s daily activities. Firefighting is
    at the crossroads – the nation can no longer afford chaos in its
    firefighting efforts.
    * A national, cabinet-level Department of Fire Safety and Prevention should be immediately organized.
    * Nationally-standardized Fire Fighting Methods should be codified and mandated in every local Department.
    * Non-firefighting duties should be outsourced to intermediate-level personnel. Shining brass, feeding the dalmatian and sweeping the station should be performed by lower-cost personnel.
    * A standard method of reporting of FIre Fighting Actions should be
    developed. Each firefighter should document the nature, kind and size
    of the fire being fought; the flammable materials ignited; the severity
    and danger of their individual duties; and finally, a self-assessment on
    how they will fight the next fire better.
    * Quality-review personnel should be required to attend each Firefighting Episode for each fire company to evaluate the individual actions of every firefighter, and tier their performance into a pay-for-performance scenario, based on their fire outcomes. (e.g. successful suppression with a utilizable structure; loss of structure, loss of life, etc.) This independent QR can be crosschecked with the individual firefighters’ accounts for discrepancy and dishonesty in self-report by the firefighters.
    * All fire types can be encoded using the International Fire Code Classification system.
    * All citizens should be required to underwrite fire insurance, or post a
    bond equivalent to a fire insurance policy, notwithstanding if they own
    any flammable property. This will standardize the costs of
    firefighting.
    * One’s previous history of fires on one’s own property or arson convictions should not be taken into account in a discriminatory fashion in setting fire insurance policy.
    * Firefighters shall bear personal liability exposure for the cost of fires which they have not fought well. Individual performance insurance must be undertaken for firefighters to guarantee their due diligence in the performance of their duties.
    * Biannual National Firefighter Certification shall be required, with continuing educational performance on such topics as Water-Based Fire Protection Systems, the National Fuel Gas Code, Fire Protection Infrastructure for Land Development in Wildland, Rural, and Suburban Areas, National Standard Screw Threads for Fire Hose Couplings and Fittings and Fire Control for Radioactive Metal Fires.

    What are some other atrocities we can think of for our poor firefighters, based on example of physicians’ obligations?

    • Rob Burnside

      Holy Haligan Tool, Batman! I get your point, Steve, and I think we’re saying the same thing, only you’re doing it with a 1,000 g.p.m. deluge gun to my 1.75″ pre-connect. Good job.

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