Leadership Traits

Think of a leader.  It doesn’t have to be someone you personally know.  It can be, but George Patton, Martin Luther King Jr., Alexander the Great, Jane Addams, and Bill Belichick are leaders, as well.  Think of a leader and think of 3-4 traits that they exhibit that makes them a good leader.  What are the adjectives that describe their leadership skills?

Winston Friggin' Churchill
By J. Russell & Sons [Public domain], via Wikimedia Commons

This all relates to a lecture that I have and occasionally give about leadership.  It is specifically about the different academic theories of leadership and how leadership is viewed by academics – sociologists, psychologists, and those kinds of people - rather than a how-to, skills based leadership class.  In the lecture, I explain that one of the earliest theories used to explain the process of leadership is what is called the “traits approach.”  In short, it looks at what traits successful leaders have.  

It should be pointed out that leadership is separate from management and administration.  You don’t have to be a leader to be a manager, administrators are not necessarily leaders, and so on.  The three roles are separate.  That is why leadership is non-positional.  The most influential leaders in your organization may be regular line medics.

Anyway, the traits approach to describing leadership began in the 19th Century, but took off in a scholarly sense after World War II.  Right after the war, the United States took detailed retrospective looks at what was done during the war; what was done right, where improvement could be found, and such.  They looked at strategic bombing raids, why some men kill and others don’t, why some leaders were more successful than others, and dozens of other questions.  

In 1948, one of the first academic (rigorous and peer reviewed) pieces was published.  Stodgill published a meta-analysis of 124 other studies of leader traits.¹  The main traits he found to be common in successful leaders were: 
     -intelligence
     -alertness to the needs of others
     -insight into situations
     -responsibility
     -initiative
     -persistence
     -self-confidence  
Stodgill updated his meta-analysis in 1974 with an additional 163 studies.²  The updated traits seem to have been influenced by the 1960s: 
     -drive for responsibility and task completion
     -vigor and persistence in goal pursuit
     -creative problem solving
     -stress absorption
     -social initiative
     -self-confidence
     -accepting of decision consequences
     -toleration of frustration and delay
     -capacity for group organization  
The search for traits is still being continued in more recent studies, as well.³

Compare the two lists.  Was intelligence not needed in 1974, as it was in 1948?  Of course not.  So why is it on one list and not the other?    

Do you have to be intelligent to be a politician?  I would argue that the opposite is the most beneficial option when considering politics as a career.

Is it vital for a CEO to be accepting of the consequences of her decisions?

One thing that is missing from both lists is being skilled at whatever the people you are leading are doing.  Is it important to be a good football player in order to be an inspirational, competent football coach?  Seriously, think about that one.

Why in the name of all that is good and holy is integrity not on either list?!?

The problem is that looking for common traits among skilled leaders is a non-starter.  It doesn’t work like that.  Have you ever met a bad leader with self-confidence?  Self-confidence is present is good and bad leaders, just like self-doubt is present in good and bad leaders.  There is no sensitivity or specificity to the traits – they are too generalized.  In addition, this approach to describing leadership isn’t culturally varied.  (Bear with me, I know EMS folk get glassy-eyed talking about 'culture.'  But I mean culture in a micro sense, like the culture between the fire service and Greenpeace being different.)  Does a leader require the exact same traits to lead an infantry platoon in war as a leader starting up a homelessness non-profit would require?  Of course not.  Finally, do you think you need different skills to convince a group of subordinates to charge a machine gun nest compared to the skills to convince people to fill out their TPS reports differently?  Different situations require different traits.   So the attempt to describe leadership as a collection of leader traits hits a brick wall.  

But in EMS, it seems like we really, really want it to be true.  

What is the one trait we look for in our leaders?  Skillful, experienced paramedic.  Wait.  I guess that counts as two traits.

Granted, “skillful paramedic” probably includes intelligence, problem solving abilities, decision making skills, and other traits.  But you don’t have to be the fighter pilot with the most kills in order to run the Air Force.  An army doesn’t make the best tank driver the general.  I have no idea whether Dwight Eisenhower could hit the broad side of a barn with a Garand, but he led a coalition of soldiers across Europe.  Who cares if he could shoot, that wasn’t his skill set.  Most organizations identify potential leaders early in their careers.  Future leaders are even hired separate from line workers.  The organization advances their levels of responsibility slowly, and trains the shit out of the potential leaders at every level with specific leadership and management skills.  In many fields, cross pollination occurs - a manager at Coca Cola can be hired by General Motors, rather than GM being forced to promote from within.  Some days, I wish we did things like that more in EMS.  

The manager being groomed at Coca Cola doesn't have to lead paramedics.  Knowing my peers and coworkers, their alpha personalities and remote worksites, their downtime, their stress levels, the expectations of their jobs, and their feelings towards authority, it almost seems like you are setting up failure if you don't specifically give a new leader tools, education, training, and mentorship.  A newly made supervisor (I love that term - made - seems like the mob) should be devouring leadership and management books like s/he was devouring medical books immediately after paramedic school.  

If you’ve ever had a skillful leader as a boss in EMS (and, amazingly, I have had many), remember that it is probably through blind luck or personal talent rather than through a process of development and skillset training.  

I work in an agency that gives new leaders those tools, and I am especially glad for it.

1. Stogdill, RM. Personal factors associated with leadership: A survey of the literature. Journal of Psychology 1948; 25: 35–71.

2. Stogdill, RM. Stodgill’s Handbook of Leadership. New York: Free Press; 1974.

3. Along with the Wikipedia bibliography, see: Hoffman, BJ, Woehr, DJ, Maldagen-Youngjohn, R., & Lyons, BD. Great man or great myth? A quantitative review of the relationship between individual differences and leader effectiveness. Journal of Occupational and Organizational Psychology. 2011; 84(2): 347-381.

The Continuum of Agitation

I was cruising through downtown a while back in the ambulance when I was flagged down by bystanders to some drama on a street corner.*  They told my partner and me that there was a fight a block or two ahead and someone was probably hurt.  We did what most paramedics would do in that situation - we made a right angle turn and continued about our day.  I don’t need to break up a fight.  As we drove, though, more and more people saw us and began to flag us down.  There comes a point when you can’t avoid a call.

When we arrived on scene, we found two adult males with minor injuries to their faces.  One had a nosebleed, I recall.  My partner took care of the both of them, so I don’t really know specifics.  Instead, I walked up to a shouting man being restrained on the sidewalk.  He was a big dude, not fat but big, and seemed rather upset.  As near as I could make out, the bystanders thought he was the aggressor in the fight and were holding him down.  One bystander was sitting on his stomach (knees on either side of him), while different bystanders were each holding down an arm.  So he was lying on the ground, supine, with his arms straight out from his body.  When I say upset, I mean that he was loudly, profanely, and constantly explaining how he was going to kick all of our asses.  He singled me out specifically, mentioning my shirt.  (That always makes me sad.  All I did is approach.  What did I do to deserve an ass kicking?)  Anyway, it didn’t seem like a good idea to let him up.  I did tell the bystanders to make sure to not put so much weight onto him that he couldn’t breathe but with the constant volume of air and noise he was putting out, ventilation was obviously not a problem.

I took a minute to make sure the law was headed our way and checked in with my partner.  He was handling his patients with no problems, and they didn’t even appear to be heading toward ambulance transport.  Getting more of the story, it seems like there was an altercation, the prone angry man punched the two other dudes, and a whole bunch of bystanders took him down and held him there.  

By this point, the police were beginning to show up.  Three police officers replaced the three bystanders in holding the angry aggressor on the ground.  One took his legs and two more took an arm each. To restrain his arms they used nunchuks at his wrists.  Keep in mind that the dude is still bellowing threats the whole time.  The police rolled him prone in order to handcuff him.  I threw out another reminder about facilitating breathing, but the police were doing their thing.  They weren’t getting violent and didn’t have much weight on him.  In any case, though, the patient seemed to get more and more violent - to the point that a single policeman on an arm couldn’t control that extremity alone.  He was putting out enough force to pull a cop with one arm.  And doing it on each side.  And shouting profane threats of extreme violence the whole time.

So at this point, I knew that things were escalating to the point that the man probably wouldn’t be arrested for assault and transported to jail.  His agitation was increasing to the point that chemical restraint would be helpful.  That was my plan at that point, at least.  The cops had the patient prone by this point and were working on getting both arms behind him at the same time.  The patient began to bellow that he couldn’t breathe.  

“I CANT BREATHE! I CAN’T FUCKING BREATHE!!”  Well, there is my cue.  I had been weighing my options: a typical anti-psychotic, a benzodiazepine, or Ketamine.  With the breathing screams, I got the Ketamine and a syringe.  As I drew up a 500 milligram dose, the patient began to roar.  Have you ever heard a patient roar like an animal?  The point when they no longer communicate with words, instead they can only make a rage noise?  That is excited delirium.  The patient was now experiencing a life-threatening emergency.

Similar to a police department’s continuum of force, I think agitated patients present with a continuum of agitation.  They don't line up in a 1:1 way, like how you should respond to patient actions, but they are similar in that it is an escalating pattern of actions.  The agitation continuum starts with being upset or angry, like this patient probably was just before the fight.  Occasionally, though, angry leads to violence.  Being in EMS, we forget the fact that violence is rare and unusual.  The patient in this case was in this stage when he was punching people.  Up to this point it is a police matter.  The treatment for jerks is cops.  Being angry is not a medical problem.  Being violent is not a medical problem.  

Moving on, while this patient was on the ground, he was moving into the next stage of the agitation continuum - unreasoning.  There is no way that we were going to let him up.  But that is what he seemed to expect: “Let me up you assholes! I’m going to kick all your asses!”  He’s far enough into the continuum that statements like that one don’t seem unreasonable to him.

If the agitation trail he is running down isn’t stopped, excited delirium is the end point.  I have found that complaints of breathing problems is the marker for the transition to excited delirium.  When a patient screams that they can’t breathe, especially when they can hit that really terror-filled note with their voice, that is the point that things have gone really, really bad and we’re now in an emergency.  

Roaring follows.  To me, roaring means that the patient’s body systems are under enough stress that their humanity has stopped functioning.  They are making the same noises, with the same thought processes, that a deer makes when a cougar is on its back.  It is pure lizard-brain level animal response.  

Their lower brain knows that they are about to die.

Look at the video here.  It is one of the best examples of excited delirium on YouTube.  Right off the bat, the shirtless dude is acting squirrelly.  But he is making sense.  That quickly changes into unreasonableness as he stumbles into traffic.  He is controlled enough that in the first minute the responding officer can pretty much cuff him alone with the aid of a carotid restraint.  In this case, the "help me" cries (~3:00) are equivalent to the breathing statements discussed in this post in that they are both requests for aid that make no sense.  The patient begins roaring by 3:45 when he is being carried.  The patient dies (by my eye) at about 5:25; the police begin to realize that fact at about 7:00.

Here is another great example.  The roaring is fully engaged by the 9:00 mark.

Ketamine is perfect for this situation, if it is given quickly.  It stops the patient’s struggles without affecting their breathing, like a benzo would.  They can breathe off all of the acidosis and carbon dioxide they need to.  Don’t interfere with their breathing, let them blow off all of those bad things.  

I darted this dude right through his pants.  I may have even stabbed through his wallet.  What can I say, I was in a hurry.  The police got him handcuffed, but he was prone with his arms behind him.  That is a suboptimal position.  He was still roaring and kicking, so it was impossible for me to convince the police to roll him onto his side.  I did convince them to not put any weight at all on his torso - there was only one officer holding his legs.  I felt like I was watching a horse race between Ketamine and death.  One or the other was going to hit this patient first.  

Ketamine won.  After about a minute (a minute that felt like five), the patient quickly slowed down and then went limp.  With some more begging and pleading, I convinced the police to uncuff the patient and roll him onto his back.  He had good chest expansion, good ventilations, and was tachypneic as all get out.  Perfect.  One thing I will tell you: If you have never given Ketamine before, it is kind of scary.  All of your training and experience is telling you that this patient needs a tube.  Dude has a GCS of 3!  Intubate him!  

Do. Not. Intubate. Him. He is fine.  He may need some suction, but don’t get too aggressive with his airway.  

The patient really looks dead.  That is how fast and how solidly the medication works.  The first time I gave Ketamine, I sat there with a finger on the patient’s carotid pulse.  I could feel the pulse and breathing at that finger.  It was the only way I could convince myself that the patient wasn’t dead.  

Go ahead and start all of your other paramedic stuff - an IV is probably warranted, along with an ECG and oxygen saturation monitoring.  You will want to  restrain the patient on the bed, both because they may wake up again and because their arms will flop around if you don’t secure them.  Go to the hospital with the lights and siren.  Excited delirium is a big-deal life threat.  

The most important point to take home from this post is that “I CAN’T BREATHE!” is the patient telling you that excited delirium is taking hold.  Get the Ketamine.

*So much has been changed about this story that it is now purely fictional.  It is actually best described as a conglomeration of a few calls rather than a case study of a specific patient.

My Shirt Comes Off Now

I used to drive to and from work in uniform.  I live about 30 minutes from work, on a good day.  When traffic gets thick it can be 45 minutes or so, from time to time.  It’s not bad.  I like the alone time, and I can just sit back with some music or an audiobook.  Not a big deal.

A few years ago, traffic was much worse than normal.  With the extra-long commute, I had extra opportunity for consuming excessive amounts of diet soda.  By the time I got off the highway, I was pretty sure my skin was taking on a yellowish tone.  As the saying goes, my back teeth were floating.  I was in a situation – a wide-eyed, diaphoretic situation.

I screamed into the lot of the first gas station off the highway.  My car was drifting sideways, tires smoking, and I squealed to a stop.  I leapt out and sprinted for the front door – I’m not sure I even shut the door on my car.  I ripped open the gas station door with the little chime and bellowed, “Bathroom! Where’s the bathroom?!?”  The attendant pointed me to the back of the store.  I took off in the direction she had pointed and found the restroom door.  

It was locked.  “Key! Where’s the key?!?” I screamed.

The attendant was running in my direction with a handful of keys gripped in her fist.  On the way, she was telling me how glad she was that I was here.  How nice of her to run, I thought.  She must be able to see my agony.  She is quite obviously a very considerate lady.

You would think that my brain would have caught on to the fact that all of this was weird, right?  In my defense, I think my synapses were awash in panic and suprapubic pain.  I really, really had to take care of business in the restroom.  But it is not normal to have a gas station employee be glad for you to use the bathroom, let alone hurry to get it open for you.  

The fog started to lift.  Wait a minute.  Why is she so glad that I am here?  I mean, I’m glad that the gas station is where it is, but why would she care that I have arrived to brighten her day with gallons of waste and groans of relief?  

Right about then, she got the bathroom door open.  As soon as there was room for me to fit between the door and jamb, I rushed in.  Inside I found an unresponsive dude with his pants around his knees lying on the floor.*  There was a needle in his arm, a belt around his bicep, and very slow wet snoring sounds coming from his face.  

Goddammit, of course there is a junkie in the bathroom, right now.  What else would there be.  The panic really set in at that point.  It’s not that I didn’t want to help, but I had to take care of a personal matter.  Plus, paramedics don’t like to admit it, but our jobs are pretty equipment dependent.  We like to tell ourselves that our brains and experience are our most important assets, but it is not true.  The bathroom ranger on the floor in front of me needed Narcan, not my brains.  An NPA and BVM would have helped.  I had a full bladder, but was fresh out of Narcan, NPAs, and BVMs. 

Thankfully, I was rescued almost immediately.  I had enough time to open my mouth in a look of dumbfounded disbelief before I heard behind me: “What do you have?”  It was the local firefighters from the suburban ALS department.  They were likely to possess Narcan, NPAs, and BVMs.  So I was extremely happy to see them.  But I definitely did not want to see them work this guy in the only crapper of this gas station.  (I needed it. Plus, who wants to work in a bathroom? That’s just nasty.)

I said, “Hiya, fellas.  Looks like a narcotic OD.  Let’s get him out of the bathroom so we have room to work.”

Godblessem, that’s exactly what they did.  One firefighter got the armpits, one grabbed the knees, and a third pulled Captain Bathroom’s drawers up.  As they moved him from the bathroom to the hallway, I stepped around them into the john.  As soon as the patient was out of the door, I closed it.  Those firefighters were my heroes that day.  

Ahhhhhhhh.
(By Weissman (own work), CC-BY-SA-3.0, via Wikimedia Commons]

Business was taken care of on both sides of the bathroom door. We shared a laugh about it when I was finished.  The firefighters were as confused to see me on their call as I was to stumble into an OD job.

The gas station attendant had happened to call 911 just a few minutes before I performed my tire squealing drift into her lot.  All she saw was a man in a paramedic uniform run into her store, right after she called for help.  That met her expectations exactly.  She couldn’t identify that my uniform was from a different jurisdiction.  She thought I was a responder.  

Thus, I don’t wear my uniform shirt to and from work anymore.  People can’t identify the 5.11 tactical pants I wear as EMS pants.  They just look like blue cargo pants, if people even look that closely.  The uniform shirt is pretty obvious, though.  Rendering aid without equipment is difficult, and I would rather be the one to make the choice to engage a call.  Nobody wants to be forced into it with a full bladder.

*I used to wonder what the matter with people was.  They really needed their pants down?  What is that, multitasking for addicts?  Who has time to poop and shoot separately?  Come to find out, it actually is in case their hit causes them to lose control of bowel continence.  That's why so many ODs are in a bathroom sans pants.

Advance Directives Are Simpler Than We Make Them

Last week I posted a scenario to illustrate ethical frameworks.  The scenario is a common one, which EMS providers will confront many times in their career.  What is interesting to me is that I used it as an ethical scenario, but it may have illustrated to me poor understanding of advance directives among EMS providers.

You respond to a cardiac arrest to find a pulseless and apneic 65 year old male.  There are six or eight of his family members around, as well.  The patient has a valid DNR, but the entire group of family members say to work him.  What is the right thing to do?  

On one side, the DNR says to pronounce him.  On the other side, there are a whole bunch of upset people who want you to work him.  They are going to get even more upset if you don’t.  Plus, death is the irreversible choice.  It is the option that you can’t come back from.  What is the right answer?

The right answer is to pronounce the patient.  I cannot say that more clearly.  Pronounce. The. Patient.

The reason for that is based on the four main ethical principles of medicine.  Beneficence is having the welfare of the patient as your main goal.  Nonmaleficence is avoiding harm and avoiding ineffective treatments.  Justice is the act of ensuring your skills are evenly spread through society - not just caring for rich people only, for example.  Finally, autonomy is the ethical principle that holds that people should be allowed to make their own decisions about what medical care they do and don’t receive.

Autonomy is the primary principle in this case.  People are allowed to choose what care they receive (and don’t receive).

Advance directives are instructions that are given while a patient is able to make decisions, but are held for the future when they can’t decide.  Advance directives include living wills as well as various do-not-resuscitate forms.  Living wills are more complex forms that have extensive choices about enteral feeding, antibiotics, proxy decision makers, and that kind of thing.  They can get up to 20 pages or so (which makes them a pain in the ass for prehospital providers).  The good news is that they usually have a page that hits the high points, like an executive summary for CPR instructions.  But that is not what I am talking about here.

Do-not-resuscitate forms have various versions.  In Colorado, the most common form that I have been seeing recently is the MOST form.  I love that it has Yes CPR/No CPR right at the top where it is easy to find.  Anyway, with CPR directives, there is a spot at the bottom for a physician signature - this shows that a provider discussed the options with the patient, they were competent decision makers regarding their care, and the listed choices are the patient’s choices.  

Notice what the form doesn’t have: A spot for daughters, sons, grandchildren, and so on to sign.  Because nobody cares what they think in this case.

An adult decision maker doesn’t need anyone’s permission to institute advance directives.  They don’t need to tell anyone else.  They don’t need to discuss it with anyone else.  Many patients don’t discuss these decisions with most of their family members.  They may feel it is a private decision.  They may feel that the family members would disagree with their decision.  They may feel that the discussion would be uncomfortable and best avoided.  Whatever their reason is, I don’t care.  The guiding principle for me is the same - people are allowed to choose what care they receive and don’t receive.

They have a form that tells me what they have decided that they want, after a discussion with their primary care provider explaining their options.  The PCP signed off that the patient was making a rational decision.  All of that, along with what their decision is, is contained in the DNR form.  So show me a CPR directive, MOST form, or other DNR-type paperwork and I will call for a time of death.*

It is uncomfortable when you are the one to tell them, but family members can’t rescind a DNR form.

Oh, yeah, that brings me to another discussion point.  Durable medical powers of attorney.  “I’m his power of attorney, and I say to do everything you can to save him!”  The only person that can rescind an advanced directive in Colorado** is the person who made it.  So a POA can rescind the DNR, but only if they are the ones who made the decision and signed the form.  If the patient made the decision, signed the DNR, then made their kid DMPOA, then croaked - sorry, the patient is the only one who can take the DNR back. The DNR takes precedence over the power of attorney.  The only way a POA can rescind the DNR is if their signature is the one that is on the bottom of it.

*Technically, a MOST form is a way to lay out medical orders.  Medical orders can be changed by another medical provider.  But the MOST orders do clearly communicate the patient’s wishes, which should be honored - even when it makes their family members really sad.  My opinion is that you will be best off when you focus on the patient’s documented wishes.  Don’t complicate a call when you don’t have to.

**All of this is for Colorado.  Each state has their own specific statutes and forms.  I don’t know about different states or other countries.  Google it, baby.