Few things weave their way through all aspects of what we do like the clock. Make your response times (less than 8 minutes, 59 seconds 90% of the time), have fast hospital turn-around, do two minutes of compressions prior to shock, ventilate if you can't get the tube in 15 seconds, transport people who are shot to the trauma center in less than 10 minutes after you reach them, give your estimated time of arrival to the hospital, count the minutes between contractions, give epi every 5 minutes, show up to work on time, donate time to plan the holiday party, work overtime, take time to relax, make time for your family, and, and, and. It's time we had a frank talk about stress, myths, tricks and traps of the most common unit of measurement in EMS.

     Imagine, if you will, a group of folks at a dinner party, sitting in a circle around a big clock-shaped table that looks like something out of a Salvador Dali painting. While eating a healthy, organic, low-fat, carb-free, yet tasty meal, washed down with antioxidant-rich, heart-healthy 1999 Napa Valley Cabernet Sauvignon, they chat about time. Our guests include a paramedic, a man who's having difficulty seeing out of his left eye and seems a bit confused, an EMS system administrator, a woman with sparkly earrings and chest pain, a discharge planner who works on the geriatric med-surg floor at Our Lady of Great Agony Hospital, an 11-year-old whose ankle snapped while sliding into third base, and a kid with a stab wound in his belly, courtesy of a local gangbanger. Each diner has his or her own view of the clock. Like the six sightless men in the poem Blind Men and the Elephant by John Godfrey Saxe, the people around our clock are trying to convince each other that they have the right view. Eventually, social norms fall to the wayside, and they say what they really think.

PARAMEDIC
     You know, it seems like most of the calls we run aren't "real emergencies." I hate to say it, but nothing bad would happen to most people if it took us an hour to get there. I know, there are a few patients who would be dead or spend the rest of their lives dragging an oxygen tank around, or having some nurse's aide wipe drool off their face while their Depends droop if it weren't for me. But not many. Now, we run hot to everything because dispatch once sent us nonemergency to a "sick case" that turned out to be the mayor's dad having the big one. It's like one kid gets caught sticking a wad of Juicy Fruit under his desk and then it's no gum for anyone.

     To me, the clock is a big thorn in my gluteus maximus. Dispatch holds me over at the end of every other shift for a late call without so much as an "I'm sorry." Yet, if I'm late for work by just one minute, I'm on the path to getting fired. My supervisor says "late is late" when she hands me my disciplinary letter. They want us out of the hospitals in 20 minutes or less. Hell, I'm lucky if I can get a nurse to talk to me in 20 minutes, much less get our patient transferred, print the hospital's copy of the ePCR and empty my bladder in the time they allow. Screw their standards; I'll just do the best I can.

     One more thing about time: I've been around this business since the days of Build-A-Boards and Cadillacs. I remember when digital watches first came out and all the rookie medics recorded 60 for every pulse they took for the next two months. Now, those same college boys are running things.

MAN HAVING DIFFICULTY SEEING OUT OF ONE EYE
     I'm not sure what's going on. My left eye is bugging me, and I can't see out of it all of a sudden. I've put some of those "get the red out" drops in, but it's not getting better. Wine is dribbling out of the corner of my mouth and I'm not sure why. If my brain could talk, it might say, "Help…part of me is dying. If I don't get help quick, I'm going to lose all of junior high school."

     What does the clock mean to me? If there's one of those brain attack intervention hospitals near me, I'll get there quick, and they'll put in that little basket to scoop out the clot so more of my brain will survive. You could say that my clock started ticking when I quit taking my blood pressure medicine, but the emergency part of this stroke started as soon as I started feeling off kilter. Mind you, I didn't call 9-1-1 for a while because I thought it would get better. My clock will stop when they open up my clogged artery and restore blood flow to my brain.

     For me, the clock is the difference between playing golf and staggering around with a droopy face for the rest of my life.

EMS SYSTEM ADMINISTRATOR
     As the steward of the system, I have to make sure the community is getting what it's paying for. I know the quality of clinical care and customer service are what's really important. Those things are hard to measure accurately. Consequently, it is hard to hold providers accountable to those kinds of standards.

     What I can measure is response time. It may not be the best measure, but a couple of decades ago, those folks in Seattle, who still seem to have more cardiac arrest saves than the rest of us, said if they got ALS to the scene in 8 minutes or less, more people lived.

     That's good enough for me. And until you can show me better "evidence," I'll fine you $15 for every minute over 8:59 and throw your company out of town if you fail to make 8:59 better than 90% of the time. Why :59 you ask? The clocks used in those original studies didn't measure seconds, so their times could have been 7:01 or 8:59. I'm giving you a break by letting you go to the very edge.

WOMAN WITH CHEST DISCOMFORT THAT'S GETTING WORSE
     It started as a faint whisper under my breastbone a couple of hours ago. But now my jaw hurts and I'm panicky. I called my daughter's boyfriend, Robby, who's in dental hygiene school, to see what I should do about the jaw pain. He didn't answer. My best friend, Sara, lives next door, so I walked over and asked if she would drive me to the hospital. She got scared and called the paramedics. Now, I'm really scared. I can't catch my breath.

     If my heart could talk, it would say, "I'm dying here…do something NOW!" What does the clock mean to me? I know it probably started with ordering "a Biggee, please" when asked, "Would you like fries with that?" Maybe it was that pack and a half of Virginia Slims every day. But this heart attack started with a faint whisper in my chest. I knew on some level that something bad was happening, but I didn't want to admit it. Denial is not just a river in Egypt.

     What does the clock mean to me? The faster I get my coronary arteries Roto-Rootered, the better I'll be able to walk up the stairs to my apartment without having to stop every three steps to suck wind.

KID STABBED IN THE BELLY BY A GANG MEMBER
     I was minding my own business when some dude hit me and knocked me off my bike. I didn't even see the blade in his hand. Didn't know I'd been cut until that girl screamed. It doesn't hurt much. I thought gettin' stabbed was supposed to hurt more. I'm gonna lay some pain on that punk who cut me.

     What does the clock mean to me? They say that all bleeding stops eventually. I'd like mine to be stopped by a surgeon in the OR rather than because my tanks run dry, if you know what I mean.

11-YEAR-OLD WHO SNAPPED HER ANKLE SLIDING INTO THIRD BASE
     I just learned how to slide last week. My dad caught it on his cell phone video…it looks really cool. You can see it on YouTube! Today I was running so fast, and somehow my legs got tangled when I started to slide. I heard a crack, and I didn't make it to the base. Dad came running over, but I didn't know anything was wrong until I tried to get up. It hurts really, really bad. I don't want anyone to touch me.

     Dad's yelling for someone to call an ambulance, get the first aid kit, call my wife, do SOMETHING! I'm really embarrassed with everyone looking at me, but it really hurts to move. I think it's broken.

     What does the clock mean to me? Every second that clicks by before they give me something for the pain seems like a whole year.

DISCHARGE PLANNER WHO WORKS ON A GERIATRIC MED-SURG FLOOR AT OUR LADY OF GREAT AGONY HOSPITAL
     The emergency department just called with three more admissions. The ED secretary said they're getting backed up again. I called Dr. Smith to ask if she'd discharge the patient in Room 42. She's so nice; I think she skipped lunch to help me out. She stopped by and signed Jake's discharge papers. Before her pen stopped moving, I was on the phone to the ambulance service to take him back to Our Lady of Perpetual Indulgence Nursing Facility. Of course, that was almost two hours ago. The dispatcher said their ETA was 3 o'clock; it's now 3:30. I guess I should have asked if they meant AM or PM.

     What does the clock mean to me? It means Mrs. Johnson is in the hallway of the ED waiting for Jake's bed. Those ambulance people are always complaining about getting delayed in the ED. Well, if they would get Jake out of here, a bed would open up and there would be one less ambulance parked in the driveway.

WHAT DOES THE CLOCK MEAN TO YOU?
     Well, dear reader, would you like to join us at the clock table? What does the clock mean to you?

     One of the magical things about time is that it is a great equalizer. You, Bill Gates, the guy hitting you up for spare change and I have the same number of seconds, minutes and hours in our day. For the sick and hurt people we care for, time matters. Even if quick action only makes a clinical difference for a handful of our customers, from a stress-management and customer-service perspective, it makes a difference to almost everyone.

     We analyzed nine years of computer-aided dispatch data for 3,292,403 EMS calls that resulted in a ride to the hospital from EMS agencies all over the U.S. We spend an average of 53 minutes and 49 seconds handling a call from the first keystroke logging information into the CAD until the crew is back in service. Figure 1 shows how this breaks down.

     When you look at time from the patients' perspective, our data is incomplete. Think about someone having a myocardial infarction. His clock starts with the onset of symptoms, but a study published in the May 12, 2008, issue of Annals of Internal Medicine found that people waited an average of 115 minutes before seeking help. In most communities, when patients call 9-1-1, the phone is first answered by a primary public safety answering point (PSAP) and then transferred to EMS or fire (secondary PSAP). Few systems measure time from when the phone is answered in the primary PSAP until the caller is transferred to the secondary PSAP. In the systems where it's been evaluated, the time varies between an average of 22 seconds to more than 5 minutes.

     From the patient's perspective, the response time doesn't end until someone in a uniform says, "Hi, my name is ______. What's going on with you today?" For him, pulling our ambulance into the emergency department driveway is not the beginning of definitive care. For our MI patient, the clock stops when the little balloon on the end of the catheter wire puffs up to reopen her coronary artery. It's probably time for us to ask patients when their symptoms started and add that to their patient care record. We should also begin capturing at-patient times and, if we can get it for some patients, the time to intervention in the hospital.

     For most of our patients, the times related to their asthma attack, bicycle crash or belly pain are some of the most memorable moments in their lives. An important question to ask yourself is, "What am I doing during this time that makes a difference?" While you're taking vitals, placing the electrodes for a 12-lead or setting up the CPAP equipment, are you helping the patient feel as comfortable as possible? Is there anything else you could do to help them improve their health? Could you chat with them about seat belt usage, or how much longer they might live if they would just see someone about that high blood pressure?

     Please don't take anything in this article to mean that call-processing time, out-of-chute time, response time, scene time, time to first shock and the like is not important…because it is. The mistake we make in this crazy business is to think that the small time components are what matter the most. Research shows that people who eat lots of blueberries have lower cancer rates than people who don't. The theory is that the antioxidants in blueberries are the key ingredient to fighting cancer. However, in the studies where people took just the antioxidants, the cancer rates went up. Don't make the mistake of focusing on response times or chute times or scene times by themselves. Think of the whole time from the patient's perspective. Eat whole blueberries.

     Finally, the truth is that I was late submitting this article. I finished it in a Chicago hotel room, where I was stranded for the night because my flight got in late and I missed the connecting flight.

     Special thanks to our friends at FirstWatch who crunched through millions of 9-1-1 call records for this article.

     Mike Taigman is a lifelong student who strives to be on time for meetings. Contact him at www.emsleader.com.

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