Brungardt Law's Lagniappe
A little extra perspective from Brungardt Law conveyed through conversations with individuals of various backgrounds exploring the interplay of practices, policies, and laws with decision making and leadership. An opportunity to learn how to navigate towards productive outcomes as well as appreciate the journey through the experiences and observations of others.
Brungardt Law's Lagniappe
Short Staffed, Underpaid, and Saving Lives: A Conversation with Dr. Meg Marino
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Despite limited resources, the men and women of New Orleans Emergency Medical Services (NOEMS) consistently provide quality emergency medical care through unparalleled professionalism and passion. In this episode we are fortunate to engage with Dr. Meg Marino, the Director of NOEMS since 2021. Dr. Marino has been interested in and dedicated to the development of pre-hospital emergency medical care since her residency. She shares her thoughts regarding the successes, challenges, operations, administration, and, most importantly, personnel of NOEMS.
Annually, there are over 40 million 911 calls. Responding to those calls are over 12,000 emergency medical services agencies in the United States, and approximately 282,000 emergency medical technicians and paramedics. Who are the people providing that critical care to patients during the golden hour? What goes into leading the personnel and managing the programs of an EMS agency? Welcome to Brungart Law's Langout, wherein we provide you a little extra perspective beyond the law, through conversations with individuals from all walks of life. I'm Maurice Brungart, your host. I enjoy engaging with experienced, knowledgeable, and passionate individuals for the opportunity it affords to broaden and deepen understanding of the world through their eyes. The more we learn, the more likely we can become better versions of ourselves and guide others towards the same. Today's guest is Dr. Meg Marino, Director of the New Orleans Emergency Medical Services. She's a pediatric emergency medicine specialist, as well as a children's book author promoting the development of emotional intelligence and empathy in children. Welcome to the program, Dr. Marino.
SPEAKER_02Thank you so much for having me. I appreciate the opportunity.
SPEAKER_00Well, like I told you before, it's a privilege for me. I appreciate the confidence. Tell us about yourself.
SPEAKER_02Well, I was born and raised in New Orleans. I studied French in college at Loyola University in New Orleans. I decided to go to medical school after my little brother developed brain cancer and ultimately passed away. But during that process, I really uh learned how to take care of people. And I felt that the things that I learned during that time could be used to help other people. So I decided to go to medical school where I uh went to school at LSU in New Orleans. I decided to study pediatrics, which I felt like was a really great way to impact the world. You know, if you're able to change the course of a child's life, um it can have a really big impact on the adult that they become. So I went to Colorado Children's Hospital to study pediatrics. I was there for three years.
SPEAKER_00Whereabouts in Colorado?
SPEAKER_02In Denver. Um in Denver, Colorado, at the Children's Hospital Colorado is a beautiful, beautiful place with mountains. And while I was there, I realized that we had a lot of EMS providers who were coming very long distances. We had a 500-mile catchment area for pediatric patients because there's really nothing near Denver. And we would care for these pediatric patients who had been in the hands of rural EMS providers that didn't know how to take care of pediatric patients. So I did a needs assessment to determine why rural EMS providers did not receive pediatric training. And it turned out that it was because of distance. They didn't want to travel to Denver for the training and they didn't want to have to pay for the training. So we applied for a grant to get a mobile simulation unit that travels to rural areas of Colorado, teaching people for free how to care for pediatric patients. And it was through that experience that I realized that you could have a big impact on a lot of patients by training EMS. If you get great prehospital care, you're able to do well in the hospital. But patients that don't receive high-quality prehospital care by EMS providers generally have poorer outcomes.
SPEAKER_00At that time when you applied for the grant, the grant was coming from a federal source, a state-level source?
SPEAKER_02Through EMS for Children.
SPEAKER_00Okay. Is that a nonprofit of some kind?
SPEAKER_02It is a it is a federal, federally sponsored program.
SPEAKER_00Is it still in existence today?
SPEAKER_02Yes. So EMS for Children is a wonderful program. I am part of the EMS for Children in Louisiana. We hope that the federal funding continues for it. It is dedicated to the idea that we need to provide high-quality emergency care for children in the emergency setting. So that's both in the pre-hospital setting via EMS and in the emergency room setting. We know that if you have a pediatric patient in a community hospital, they are 76% more likely to die than a child cared for in a freestanding children's hospital or a children's dedicated facility. And so through EMS for Children and a project called PEEDS Readiness Project, we have been focused on decreasing those variations in care between community hospital emergency departments and big hospitals.
SPEAKER_00And when you applied for this grant, what do you think motivated you in the sense of identifying what you saw as a problem, the lack of training, and actually pushing for this grant?
SPEAKER_02So I think that at the time I was very, very optimistic about, you know, that you can make a small difference, a small change and impact a lot of people. So when I applied for the grant, people thought, oh, there's no way you're gonna get that. But it it follow, you know, we followed through.
SPEAKER_00And out of curiosity, what are the results even today from that effort from years ago?
SPEAKER_02That's a great question. So I um this was more than 10 years ago. So I don't know. Um I'm not even sure that it's still working today. But at the time, it was a big uh, it it was, it felt like a big accomplishment. And um, you know, what came out of that for me personally is I realized that through educating emergency medicine providers how to take care of kids, that I could make a big difference. So I went to emergency, pediatric emergency medicine fellowship at Texas Children's Hospital following that. I was there for four years. And during those four years, I worked very closely with the Houston Fire Department EMS agency. And there we developed protocols and uh I helped develop a pediatric simulation course for uh the Houston Fire Department um paramedics and EMTs, where we, through using high fidelity uh simulators, um walked them through really very realistic um situations. So, like a pediatric drowning or a twin delivery in a bathroom or a um a child who's been run over by a car. And we were able to uh give these providers a very realistic experience on how to care for critically injured children and provide that high-quality pediatric care and save lives. Through that, I really, you know, doubled down on EMS and decided that I wanted to make it my career. I moved back to New Orleans where I worked for Oshner Hospital for Children and the Pediatric Emergency Department and in my free time went to EMS agencies to teach them how to take care of kids. Through that, I started working with the New Orleans EMS and uh really realized how amazing this agency is. We have phenomenal, phenomenal, dedicated people who just want to do the very best that they can for their patients every day. And shortly thereafter, I was offered the deputy medical director position. I thought it was going to be a fun 10-hour a week job where I uh, you know, maybe taught a little bit of pediatric uh, you know, intubations and maybe taught how to um resuscitate newborns and maybe develop some protocols. But then COVID happened and my fun little 10-hour a week job became an all-encompassing 80-hour a week position where we were really focused on how to keep our employees safe during the pandemic. We were one of the very first cities in the United States to have COVID. And, you know, looking back on it, we probably had a lot of COVID cases before we started testing for COVID. But we had to figure out how to write protocols for personal protective equipment, how to order masks, how to order gowns, make sure that we had enough N95 masks for providers to ensure their health and well-being. We developed protocols that we changed every 12 hours because new information was coming out. Initially, it said that it was safer for the patients to intubate the patients. And then, you know, shortly thereafter, they said, no, actually, it's better if you try not to intubate those patients. So we we worked really hard to both treat our very, very sick COVID patients, but also protect the health and emotional well-being of our providers. Through that experience, I I really realized how important EMS administration is. So we developed protocols for how to give vaccines, COVID vaccines to our employees, but also to the community. We developed protocols on how to ensure that everyone was safe and caring for the patients. I thankfully was able to keep our team safe and healthy. Um, we developed a COVID occupational health program here at New Orleans EMS. Um, we also realized the emotional toll that this takes on our team. And through that experience, we made the decision to hire a full-time mental health coordinator. Um, she is a social worker, a licensed clinical social worker who works 24-7 for New Orleans EMS just to provide emotional and mental health support to our employees.
SPEAKER_00She's focused exclusively on your agency, not the fire department, not the police department.
SPEAKER_02No, just exclusively on New Orleans EMS. And because of our really innovative program by hiring her, the fire department now has someone in that same role offering that same mental health support to their uh to their employees. And so it's been really wonderful to see that program grow. I know that even after the COVID pandemic kind of died down, this has been something that's been incredibly important, especially in the aftermath of January 1st uh terrorist attack that we responded to.
SPEAKER_00And we'll we'll talk about that here a little bit later on. Let's take a moment and step back. What is the path of becoming an EMT and specifically here, New Orleans EMS? I mean, I recall in another time what it took, but I'm sure things have changed.
SPEAKER_02So that's a really wonderful question. We just recently started an EMS core program. So we uh hire people that don't have any experience in healthcare, um, but have a desire to help improve the health and well-being of their community. We put them through a 20-week course where they first become emergency medicine responders. Um, they are able to go out into the community with our paramedics and EMTs and provide limited amount of care. Through that 20-week period, they learn how to um provide high-quality CPR, care for pediatric patients, uh, take care of patients who are having heart attacks or whose hearts have stopped and defibrillate or you know, use an automatic defibrillator to restart their heart. Um, they become integral members of our team. And so far, we've graduated one class, we have a second class that is in progress. We're really proud of this group. There's been a lack of EMS providers in our uh community. And so after COVID, there was the great resignation of healthcare providers, and a lot of hospitals started hiring paramedics and EMTs to backfill the nursing shortage. Because of that, we were able, uh, we were unable to recruit and retain high-quality providers because they were all being poached by the hospital systems. Because of this, we made the decision to kind of grow our own. And we've developed an advanced EMT program as well. So we're able to bring people who are EMTs through an advanced program, which allows them to start AVs, um, uh do EKGs, do a lot of things that um a regular EMT is not able to do, it brings them much closer to a paramedic level. We are hoping to start our own paramedic program. We used to have a paramedic program here um several years ago, but through a series of um accreditation, new rules, things like that, the paramedic program at New Orleans EMS went away. So we are working to reboot that right now. I think that the best way for us to retain um high-quality paramedics is to grow our own and and create a community of paramedics and EMTs who were born basically at New Orleans EMS.
SPEAKER_00And and the seeds from which you're you're growing these uh individuals, are they all local, or do you have a few people from out of state coming here?
SPEAKER_02Because New Orleans EMS is a premier EMS agency, we're one of the best in the country. We are consistently part of EMS research. We um lead the nation in blood administration. We have started programs that have decreased the murder rate in New Orleans by 30%. Because we are this premier agency, we get people from all over the country who want to work for New Orleans EMS. Unfortunately, because we pay very little compared to other EMS agencies and other hospitals that are hiring EMTs and paramedics, it's been very difficult for us to recruit and retain high-quality paramedics and EMTs. But we do get people interested in coming to New Orleans from all over the country. I think that the best way for us to grow our department is to look to the community that we serve. And that's why we started the EMS Core program, where we recruit people from the New Orleans area to serve New Orleans citizens and visitors.
SPEAKER_00Speaking of your team, so to say, and those that you've been recruiting locally, um give us a breakdown of the demographics of New Orleans EMS.
SPEAKER_02So we have about 150 um paramedics and EMTs and advanced EMTs that work for us. Um we've got uh a lot more women than other EMS agencies do. You know, historically, EMS has been a male-dominated field. And I think that having uh women in leadership at New Orleans EMS has really helped to make women feel empowered in joining EMS. I'm often the only woman in the room in the meetings that I go to with EMS leaders from all over the country. I think that it's important to have representation at the top, and I think that that helps women who want to pursue careers in EMS uh take the lead.
SPEAKER_00Uh focusing briefly on that particular aspect, uh, more women in EMS and in positions of leadership and authority. How would you address someone say, okay, here we go again with the whole diversity uh wokeness uh sort of approach to employment of individuals? What is your response to that?
SPEAKER_02That's a really great question. You know, I really believe that I have every, you know, every advantage uh in the world. You know, I'm a a physician, I have, you know, risen to the top of the leadership structure at New Orleans EMS. I'm well known as a um nationally known speaker, and uh I've been at the top of my game for a little while now, and I feel very proud of the work that I've done. And I don't think that I've been treated any differently because of my gender, but I do know that there are a lot of people who have been treated differently because of their background or because of their gender in ways that I'll never fully understand. And so I want to make sure that I have a diverse group of people because we know that by having different voices and different people from different backgrounds, that we can really all come together and treat our community that we serve. I think it's really important for an EMS agency to have a group of uh highly trained people serving the community that they that they come from. So we want to ensure that there is representation in New Orleans EMS that reflects the community that we serve. Um and the way we do that is we work hard to recruit from our community.
SPEAKER_00Going just a little deeper, whether it's from your personal experience and you don't have to say, or if you would like to share the experience of someone else, do you believe that women have to work harder in this particular field in order to prove themselves? And do you find that standards at any point in time were lowered or altered to accommodate people from different backgrounds?
SPEAKER_02That's a great question. We have very high standards here at New Orleans EMS, and we don't lower them for anybody, for any reason. The people that we hire work hard and deserve to be here. They provide excellent pre-hospital care and we train them to the highest standards. I do believe that it's harder for women to get into EMS, not because the standards are different for them in any way, but I do believe that women don't necessarily have the same role models that men have growing up. And I think that having women in leadership, having that representation at the top, I think opens the eyes of women who may otherwise feel that these roles are only for men.
SPEAKER_00Coming back to the surface and focusing again on your agency, tell us a bit about the work environment, the challenges, whether it's from logistics. You had mentioned pay being an issue. Uh, you know, what is the standard of care that is used in the field? Uh how do you how do you pay for your program? Where is the funding from?
SPEAKER_02So New Orleans EMS is a business inside city government. So we make more money than we spend every year, and that money goes directly into the general fund for the city of New Orleans, and we support other public safety. Agencies with the money that we make. If we were to invest some of that money back into New Orleans EMS, we could make even more money for the city. Right now, we are staffed at about 60% of full staffing. And because of that, we are relying on Acadian ambulance to provide about 25% of our 911 coverage. Because of that, we lose about 25% of our billing, which equals about$8 million. If we were to raise the wages of our EMTs, paramedics, and advanced EMTs, we could recruit up to that 250 paramedics that we need to fully support our 911 services in the city of New Orleans. That would allow us to come off of the Acadian contract and recoup that$8 million in lost revenue.
SPEAKER_00That's quite a significant amount.
SPEAKER_02It is. And so this is the plan that we presented yesterday to city council and to the chief administrative officer. And we believe that we will be able to implement that in the 2026 budget.
SPEAKER_00Well, I guess we'll have to wait and find out and be following the headlines, so to say.
SPEAKER_02Absolutely.
SPEAKER_00What are your response times?
SPEAKER_02So our response times have actually been an interesting question. For those highest acuity calls, so those sickest patients that have life-threatening injuries, we're able to get there very quickly. We haven't had anyone die waiting for an ambulance. And I'm really proud of that given the limited resources that we're working with. 60% of full staffing is a huge, huge hit. And in order to get to those really good, high-quality response times, we need to be at about 350 employees. That would allow us to get to each call within 12 minutes, 90% of the time. Right now we're working with 150 paramedics and EMTs. Because of that, our response times have suffered, and we've been really open about our struggles with response times. You know, I was born and raised here in New Orleans. My family is here. If my mom falls and breaks her hip, I want somebody there quickly. When we call 911, we deserve to get a quick response, even if it's not a life-threatening incident. And so I've been working very hard to improve the response times here at New Orleans EMS. But at the end of the day, we're doing the best that we can with the resources that we've been allotted. And we'll continue to do the best that we can with the resources that we have allotted and advocate for additional resources so that the citizens and visitors of New Orleans can get the excellent pre-hospital care that they deserve in a timely fashion.
SPEAKER_00In terms of numbers, approximately how many calls does New Orleans EMS handle annually?
SPEAKER_02We handle 71,000 calls annually. And that means that about every seven and a half minutes, a call comes in.
SPEAKER_00Now, not all those calls are for emerging care, correct?
SPEAKER_02Not all of those calls are for someone who's dying. Sometimes it's choke pain. Sometimes it is a sprained ankle. But we do our best to serve all of our patients, even those with low acuity problems. What we'd like to do is change the course of those patients who have low acuity problems. We want them to be able to access health care in a way that doesn't involve the 911 system for those problems that don't require an ambulance. One way to do that would be to create a community paramedicine program, which is on the five-year track for New Orleans EMS, as soon as we're able to get to that 250 or even 350 employees. And I think that's going to take about five years for us to get there. But I believe that a strong community paramedicine program could greatly improve the health and well-being of our community.
SPEAKER_00It's interesting you used the word community, and that this is actual part of the nomenclature for this program. Uh, because a previous guest I had, he was a veteran of New Orleans Police Department. And uh, from his perspective, uh he believed that the fundamental success of any law enforcement agency was its relationship with the community. So how would you comment on that in EMS and its relationship with the community?
SPEAKER_02Wow, I really believe that our community is, you know, the heart and soul of our city. We have amazing people with lots of different backgrounds. And I think that it's important that we have a team that can provide culturally competent care to every patient that we encounter. In order to do that, we need to be engaged in our community. We need to be teaching CPR classes to our high school students.
SPEAKER_00Do you have opportunities to do that?
SPEAKER_02We did have opportunities to do that. Unfortunately, we've lost our community outreach team and have not been able to replace it due to citywide hiring freezes. But we hope that we'll be able to continue our uh outreach programs uh in the coming year.
SPEAKER_00Regarding the types of calls you're getting, so when I did a little research for EMS in general across the United States, it appeared that most causes of injury uh were falls, about 52%, 53%, motor vehicle crashes, about 26%, and firearm discharges were only 0.2%. What are your comments regarding the types of calls you're getting here? What are the predominant uh calls?
SPEAKER_02Unfortunately, there's a lot of gun violence in New Orleans, and so we do respond quite a bit to firearm discharges in New Orleans. Um, our rate of improving the outcomes for patients with penetrating trauma, so that would be gunshot wounds. We have been able to decrease the mortality of our patients with gunshot wounds very significantly. And that has had a big impact on our community.
SPEAKER_00Are there any particular uh tactical procedures you're employing that's contributed to that? And if so, what are they?
SPEAKER_02So we were we're just celebrating our four-year anniversary of our pre-hospital blood program. So for patients with penetrating trauma who are losing blood, we replace that blood very quickly. We use a water gun type device, which I think is really wonderful. It's called the Life Flow device. Um, it allows us to give two units of blood in less than five minutes. And we've had patients circling the drain about to die, absolutely unconscious, who sit up after two units of blood and say, This tourniquet is too tight. It's incredible to see how we're able to bring people back to life.
SPEAKER_00Who came up with this device?
SPEAKER_02His name is Dr. Mark Peel. He is a pediatric critical care physician who realized that there was a need for a way to give fluin very rapidly to specifically to pediatric patients. But the device uh can be used in people of all sizes, and we've seen it, you know, save the lives of patients who either need blood or fluin very quickly. And it's been remarkable, remarkable to see people come back to life with fast blood delivery.
SPEAKER_00Now, you had also mentioned the use of tourniquets uh for the benefit of listeners. Uh educate us a little bit about tourniquets, and because I remember growing up as a kid, tourniquets were always described as something as a last resort. But then in my own uh career, uh tourniquets were actually a part of basic first aid, individual first aid kits. So share with us uh the benefits of tourniquets and sort of now how that's evolved uh into use in the field.
SPEAKER_02Tourniquets are a life-saving device, and we have trained uh police officers, we have trained firefighters, we have trained community members how to use tourniquets through a stop the bleed program. We want to use tourniquets. So a tourniquet you might think of as a special kind of belt that goes around the arm or leg when there is a life-threatening injury that's causing that person to bleed out. We want to stop that bleeding. So we use a special belt that tightens and tightens and tightens until that blood stops flowing. It's something that originally was used in combat times, but we've been using it in medicine and pre-hospital medicine or in EMS for quite a while now, and it saves lives. We recently did a program with the New Orleans Police Department where we've been training them to become emergency medical responders, and we've uh given them these wonderful bags that have everything they need to save a life. These bags have tourniquets, they have uh bags to help someone breathe, they have automatic defibrillation devices to shock the heart back into regular rhythm. Um, and they have been phenomenal at saving lives. So oftentimes the police officers are the first on the scene. And giving them the knowledge and how to place a tourniquet, how to give Narcan, which is a medicine that we give to people who have overdosed on drugs and to reverse that overdose, giving them the tools that they need to save lives has been really empowering and has had a huge impact on our community, especially on January 1st.
SPEAKER_00So New Orleans Police Department has effectively been a force multiplier for New Orleans EMS.
SPEAKER_02Yes, we have trained 23 New Orleans police officers in how to become uh emergency medicine responders. Um we continue to train about nine or 10 every class.
SPEAKER_00Have you got feedback from those officers, uh, whether it's to you directly or at least to New Orleans EMS? Hey, over the weekend I had to do XYZ.
SPEAKER_02Yes. In many instances, we have seen those emergency medical responder police officers using their skills and equipment that we've given them in uh their plan to save lives. So we had um, unfortunately, we had a shooting at the Walmart a few months ago, and uh there was a police officer there who was trained in how to become how to be an emergency medical responder. She was able to give life-saving treatment to the person who was shot in those critical moments before EMS arrived. We also saw on January 1st many, many, many uh emergency medical responders, uh police officers uh give on the scene life-saving treatment to those who are injured.
SPEAKER_00Speaking of the New Year's Eve attack, um, what are the lessons learned from that for you as a leader of an emergency medical service agency and lessons learned for your paramedics, your EMTs in the field?
SPEAKER_02You know, January 1st was a really difficult time for our department. So for those of you who don't know, we had a terrorist drive down Bourbon Street, which is a um mostly pedestrian area in the middle of the night uh around 3:15 a.m. on January 1st. There were a lot of people on Bourbon Street, and um the assailant drove three blocks down Bourbon Street and then crashed into a piece of uh equipment that looked like a cherry picker. Um I had been at work all day from 7 a.m. New Year's Eve all the way until 3 a.m. New Year's Day. And my head hit the pillow at 3.15. At 3.17, I got a call that said eight people had been run over by a drunk driver on Bourbon Street. So I throw on my uniform, I go lights and sirens to Canal Street, I get to the corner of Canal and Bourbon, I get out of my car and I'm running. And I see my chief of EMS, Chief Bill Salmaron, who reports to me. He uh said, Doc, I need you to go triage. So I'm running. And I'm gonna be honest, I'm not a runner. So it's very breathless. One of the lessons learned is that I need to be able to run to the scene and not be breathless.
SPEAKER_00While carrying your equipment.
SPEAKER_02While carrying my equipment, exactly. So uh I'm on a training plan um at this point, but at the at the time I arrived very breathless to um the scene and I saw dead body and dead body and dead body and dead body. And it was then that I realized that this was more than a drunk driver. I walked down Bourbon Street assessing each patient. There were 71 patients in total who were injured or killed by the assailant.
SPEAKER_00As you were assessing, is this on an electronic pad, on a notebook, or are you just taking mental notes?
SPEAKER_02Just taking mental notes.
SPEAKER_00Are you communicating at the same time, or are you strictly focused on doing this mental assessment?
SPEAKER_02Mental assessment, we um we used a marker to mark the severity of the injuries. We used a marker on the forehead. Okay. Um to identify uh the severity of the patient. Um and you know, the French Quarter is a difficult place to work from an EMS perspective. Usually we have bike teams that respond inside the French Quarter. The streets are very close together and there are a lot of people. Um, it's difficult to get ambulances in. So we have bike teams that respond on a regular day. Then uh a golf cart with a stretcher on the back goes to get the patient from the bike team and bring the patient outside the French Quarter to Canal Street where an ambulance is waiting to take them to the hospital. It's a little bit of a patient relay race. We were not able to get ambulances down Bourbon Street because there were so many dead bodies. And I think that if I had to do it over again, and God willing, I won't have to, but I probably would have moved the dead bodies to try to get more ambulances down the street. We saved everyone that we could have. There was no one that I feel like, you know what, I really wish if we had just done things differently, we could have saved this person. When we arrived, there were 12 people who had died already. There were two patients who had injuries incompatible with life. The death toll from that day was 14. There were no patients that we could have saved that we weren't able to. And I feel really proud of that work that we did to save all of those lives. When I got to the end of Bourbon Street, uh the 300 block of Bourbon Street, the end of the scene, um, and I saw the white truck, and there were two people who were trapped underneath the truck, and I went to go assess them. This was after getting multiple, multiple, multiple patients off the scene, triaging, treating in place, and getting them off the scene. I get to the end of Bourbon Street, there are two patients trapped under the car, and I walk towards the white truck, and there's a police officer who puts his arm out to me, like a stop sign, and says, ma'am, you can't go over there. And I said, Officer, I'm the chief of EMS. I can absolutely go over there. He says, No, ma'am, you don't understand. There's a bomb in the car. And at that moment, I realized that my entire team had been in danger the whole time. We think an EMS always, is the scene safe? Before we do anything else, is the scene safe? And we thought the scene was safe. But the assailant, who had been shot by police officers by the time I got there, had a detonator in his hand. His intention, and I guess I can't really surmise his intention, but my imagination has led me to believe that he wanted to create chaos, injure a lot of people, have the helpers run in and then kill the helpers. He had placed bombs along Bourbon Street and had a detonator in his hand. I'm so grateful that none of those bombs went off. But I'm terrified by the idea that I put my entire team in danger by being there. I'm so grateful that we didn't know that there were bombs there because I believe that we saved a lot of lives. I think people, more people would have died if we hadn't gone in when we did. I think about some other instances where that happened, like Uvaldi, where a lot of people died while the team was waiting for scene safety waiting to go in. For me, I don't know what decision I would have made if at the time do I sent the knowledge. Had I had the knowledge that there are bombs all along Bourbon Street, would I have really sent my team in? Would I have gone in myself? I'm so glad we went in because we saved a lot of lives. And we did a phenomenal job getting those patients out of the off the scene in two hospitals. Um we transported 29 patients in 95 minutes. Um and I'm really proud of that. I'm really proud of the work that we did to save those lives. And I'm grateful that we didn't know. But um I'm even more grateful that those bombs didn't go off. Um, because I really uh for a long time I was laying awake at night thinking about this. What would I have done? How would I have done things differently? But now, with the information that I have now, knowing that the bombs didn't go off, I feel like we did everything perfectly. And that we were able to save all of the patients that were able to be saved.
SPEAKER_00Now, prior to this event, to this attack, had y'all already practiced a mass casualty um exercise? And how recent prior to this event did you do that?
SPEAKER_02So thankfully, we have been preparing for Super Bowl for years, it feels like. We had so many mass casualty meetings and tabletop exercises and In Site to simulation, which means that we, you know, practiced in place with teenagers dressed in white t-shirts with red paint on them, practicing getting the resources from our community, EMS agencies, working together to ensure that everything that we needed to do would happen in case of a mass casualty incident. Six weeks earlier, we had planned an event where there was a uh there was an explosion at Jack's Brewery, which is uh, it's not even a brewery anymore. It's a it's a mall, but uh at a big community space. And because of that training and because of that work that we had done to prepare for this moment, I think that we did everything as expected. The thing that we didn't do is we didn't use triage tags, which I'm gonna be honest in talking to other places that have had MCIs or mass casualty incidents where a lot of people are injured in a very short period of time. They haven't used these triage tags either. Triage tags are a uh a tag that you put on an injured or dead person during a mass casualty event when you have a lot of people who are injured. And the tag either says black, which means you're dead, uh red, which means you're have a life-threatening injury that needs to be transported right away, yellow, you're pretty sick, but you don't need to go first to the hospital, or green, and those are the walking and talking patients. Other EMS agencies have not used these tags in real mass casualty events. We always train with them, we always practice with them. But when rubber meets the road and we have these mass casualty events, we're not using them. And I haven't exactly figured out what the best method is. We used a Sharpie on the forehead. Um, we didn't do that for the deceased patients because we felt like that was um, we didn't want the families to see that when they identified the bodies. But for our red and yellow patients, we um marked them with a Y or an R on the forehead. Um, and that worked very, very well in the dark streets in the middle of the night on January 1st. And I think if I had to do it over again, I wouldn't run back to the car to get the triage tags. But I'm uh I do believe that we did a phenomenal job of triaging those patients and that we were able to, again, save all of the patients that we could.
SPEAKER_00Well, at the risk of being premature, it almost sounds like with enough events happening, unfortunately, and different EMS agencies having this experience, perhaps this is a practice that should just be cut away.
SPEAKER_02I meet with the EMS medical directors from around the world every Friday morning. Um there's a group called the Eagles, and we uh we get together on Friday mornings and we talk about struggles, we talk about best practices, we talk about our pain points, our successes. And in doing that, we've really discussed a lot about triage tags, and I think nationally we're probably moving away from them.
SPEAKER_00Is there anything particular from the January 1st attack that you've taken as, oh, this is something we should implement in our procedures or not much?
SPEAKER_02I think the biggest thing is communication sharing. Um best practice is for there to be a unified command where police and EMS leadership sit together and decide what happens next. In this instance, we had EMS command and police command, but we weren't together. And so there wasn't that same information sharing that I think would have happened if we had had a unified command. That is the one thing that and moving the dead bodies are the are the things that I I in a perfect world would change. I don't think it changed the outcome for any patients. I don't think that it meant, you know, that some patients would live or die. But I do think if we were gonna do it over again, I think the information sharing through a unified command structure is where I would um is where I would make things different. But I think all in all, our takeaways were we did a really phenomenal job in a really, really, really difficult situation. And I believe that it was because of the preparation and all of the time we spent on this over, you know, the preceding year in preparation for Super Bowl.
SPEAKER_00Did you have EMTs and paramedics who were off-duty at the time come help once they realized what was occurring?
SPEAKER_02You know, we had a full extra team stationed at the corner of Bourbon and Canal already waiting. We were the first on scene because we were already standing right there, and we had one employee who actually screamed on the radio when he saw what happened. There was a series of interesting events that led to that. I um because I'm in my role as director and medical director, as the top boss, sometimes I don't realize that when I ask someone to do something, they do it right away. And on at 11 p.m. on New Year's Eve, I asked one of our really wonderful captains to calibrate the ventilators. And what I meant was like on Tuesday, calibrate the ventilators. But he took this to mean Dr. Marino wants me to calibrate the ventilators right now. And so he went around to each ventilator and did the calibration. He was in charge of telling people to go home. So we had a whole extra team in the hospitality district just to cover New Year's Eve while grandma on the West Bank had a stroke. We had the street team ready to handle that. But we had our hospitality zone team ready to handle New Year's Eve. He didn't send people home at 2 a.m. when he was supposed to, because he was busy calibrating the ventilators and he lost track of time. And as he was coming back to Berman Street at around 3:15 a.m., he said, you know, people are going to be really mad at me for not sending people home at 2 a.m. And then this happened. I don't know if you believe in God or the universe or just dumb luck, but our response to that moment was drastically different because our really awesome captain misunderstood my direction. And I don't know that it would have changed the ultimate outcome for those patients, but I do know that knowing that we had a whole extra team of people there and ready to respond to this devastating terrorist attack made it so that we were able to provide our very best care to these patients. We didn't have a five-minute response time, we didn't have a 10-minute response time, we had a zero-second response time. We were there before the 911 call was placed. I believe that we did everything that we could to save those patients. And I think a big part of that was because we had a whole team of people ready to go.
SPEAKER_00Well, part of what you're saying resonates with the little things that count.
SPEAKER_02Yeah.
SPEAKER_00But I would maybe challenge you. Do you think that the captain actually misunderstood you? Or this is perhaps the culmination of years of interaction, the development of trust, confidence, and mutual respect that the captain didn't understand. Maybe the captain didn't intentionally calibrate the ventilators right away because Dr. Marino asked, but it was subconsciously built in because of the relationship over time. And it was no misunderstanding. It was this is what my leader has asked of me, and by golly, we're gonna get it done.
SPEAKER_02You know, I have so much trust and respect for my team, and I really do believe that they trust and respect me too. And I think that the reason why we work so well together as a team is because we trust each other. I trust this amazing group of people to work under my medical license and do all kinds of things that other EMS medical directors don't allow their teams to do. I believe in my team and they believe in me, and I think that that carries us, carries us through a lot.
SPEAKER_00Well, let's explore that briefly. How do you do that? How would you suggest to whether it's the director of another EMS agency somewhere in the States or around the world, or regardless, someone working in an organization, how do you develop that type of confidence and trust from your perspective?
SPEAKER_02You know, I've been here six years now, and I'll be honest, it took me a while to get to this place of trust. I think working beside them has been really powerful. You know, not that long ago, maybe just a few weeks ago, I was out with my team running running calls, and um we got called to a Ruth's Chris steakhouse where a gentleman was choking on a big piece of steak. He had stopped breathing. His pulse rate was 30, which is very, very, very low. He was about to die. And I reached in with some clamps, like baby, basically tongs, Dr. Tongs, and pulled that steak out of his throat on my belly in the middle of the Ruth Cristakehouse. I think that my team seeing me on my belly on the floor, trying to save somebody's life just like they do, I think that that creates a level of trust. And I'm not saying that everybody has to, you know, go out in the field and get dirty. But I do think that it helps. I think that seeing a leader do the things that they do, feeling passionate enough about saving another life that you're gonna get throw up on your shirt, I think it makes a big difference. And, you know, I learned everybody's name. I know when people are about to have a baby, I know their kids' names or their dogs' names, I know when their dog is gonna have surgery, and I text them. I care about my team on a level that I think a lot of people might think is a little bit paternalistic or maternalistic. But I really want everybody to live their best life. And I think that they know that. I've got a lot of people, we lose a lot of people to med school or nursing school, and I write those letters of recommendation with a heavy heart because I know that they're leaving us, but I'm ultimately just happy for them because I want them to learn and grow and be the best that they can be. And if that means going to medical school or nursing school or PA school or whatever, I want them to learn and grow and develop in their career and be happy. And I think that they all know that I'm invested not just in their ability to provide excellent care to our patients, but I'm invested in them as people. And I want them to succeed. And I think that they know that I'm here to help them succeed, not just as paramedics or EMTs, but succeed in life. And I think that has helped develop that level of trust so that you know what? On January 1st, when we were out there together, I had blood all over my arms, my hands were clean because I had gloves on. But when I was out there up to my elbows in blood, just like my team was, they knew I was in it with them. And I think that they know that I'm in it with them every day.
SPEAKER_00What are some misconceptions that you'd like to address that perhaps the public has about emergency medical services?
SPEAKER_02Ooh. I that's a great question. I think a lot of people see EMS as a taxi driver to the hospital. EMS providers, paramedics and EMTs do everything that a physician would do in an emergency department, but they do it in the back of an ambulance, or they do it on the street, or they do it in somebody's bathroom. They save lives and they're expected to do all of the things that a physician would do in an emergency room for a fraction of the pay. Hot and a hundred-degree weather, in the rain, on their bellies, in a pile of vomit. They provide life-saving interventions because they love this job, they love this work, and they love their communities. They want to make a difference. Nobody joins New Orleans EMS for the money. We all do it because we love and feel a call, you know, a call to serve our communities. I really think of myself as a servant leader. I work really hard to make sure that everyone in this agency has everything that they need. And I'm constantly asking, what can I do to support you? What can I do to support you? To the point where I'm sure they're tired of hearing that. But my job as a leader isn't for other people to support me in my job. My job is really how do I support the people running those 911 calls? Do you need me to bring you a water? Do you want me to bring you a hug because you just took care of some dying children? Do you want me to clean out the back of your ambulance while you take a break and eat a sandwich? Scrub the blood off the back of that ambulance while you go to the bathroom. What do you need me to do to support you? I think those are the things that I would want people to know about EMS and about what I do. I'm the I'm the top of this chain of command. But my job is to do whatever needs to be done. Even if that means, you know, wiping down the monitor, putting the back of the truck back together, stocking the ambulance. It's about it's about finding the best way to support your team. And whatever that is, that's what I'll do.
SPEAKER_00What's a piece of criticism your own team has given you? Ooh. That whether you agreed with it or not initially, but you took it to heart.
SPEAKER_02I'll give you some. Uh that's this is great. So I used to go on the radio every day. And I would say the the Oh, okay.
SPEAKER_00Yes. The EMS radio.
SPEAKER_02The EMS radio, the radio that everybody gets to listen to while they're at work. And I used to go on every day and I would say, Hey everybody, this is Dr. Marino. I just wanted to say that I'm thinking about you, that you're doing a great job. Let me know what I can do to support you, and have a great day. But they decided, at first they really liked it. At first they really, really liked it. And they were like, oh, Dr. Marino's thinking about us. It doesn't matter if it's 10 o'clock at night or a Sunday or whatever, Dr. Marino's thinking about us. And then they felt like I was just saying the same thing every day. And they were like, Well, Dr. Marino, you just say the same thing. And so I stopped talking on the radio. I used to bring them donuts. We would have like donuts with the chief. I'd go downstairs at shift change and I'd bring donuts. And then they said, you know, what about the people who don't like donuts? So I brought some hummus and veggies. Nobody likes hummus and veggies, Dr. Marino. What about those people who are gluten intolerant? What about those people who won't eat sugar? What about the diabetic employees? So I'll say I get a lot of criticism. This is just a a little bit of it. Some people say I care too much, some people say I care too little. Some people say I don't spend enough time in the field. Some people say I spend too much time in the field. I'll say that at this job I get a lot of criticism. And I think I just need to keep doing what I'm doing. I'm never gonna make everybody happy. Everyone's always gonna have an opinion about what I do. For a while I took it personally. The first, the first little bit. I'll be I'll be honest. I was uh I will I wasn't cut out for the criticism at first. But my skin grew a little bit thicker. And here we are. I feel like people don't always like their parents, you know? People don't always like their parents. They're like, oh, I hate you. I don't like that you're making me do my job. But I think at the end of the day, they respect me. I think at the end of the day they love me, even if they don't like me every day. I love them. And no matter Where I go or what I do, we will be a family, and I will always be in their corner. I've always stood up for my employees, for our team. I know that they would stand up for me. We might not always agree, but we're a family. And we get through these trials and tribulations together.
SPEAKER_00Speaking of getting through trials and tribulations, for you and for your team, what practices have been adopted in terms of remaining resilient and coming into this job day in, day out? Uh, you know, you had mentioned, well, people obviously love their community, they love this job, uh, but still there's a lot of stress involved, complicated by the fact, not well compensated. Um, so how does one remain resilient and optimistic in an environment that's conducive to just generating cynicism?
SPEAKER_02So I love our new employees because they're so bright and shiny. And they I go in and I meet with them on the first day of orientation, and I I learn their names, and we eat donuts, and they've got so much optimism, and they're so ready to help the world. And the first thing that I say to them is this job, it's really, really, really, really, really hard. And if you don't take care of yourself, you won't be able to take care of other people. There's this self-sacrificing martyrism that's expected or has been expected in the past in EMS, that you, and not just in EMS in medicine as well, that you give all of yourself, no matter what, to make sure that you're taking the very, very best care of patients, even if that means that you don't sleep. I grew up in medicine where we still did 36-hour call and 36 hours would turn into 48 hours, and you know, you'd just be at the hospital for days and days. That's not helpful. That's not good for anybody. We need to set boundaries and barriers so that we can take care of ourselves. If we're not taking care of ourselves, we can't take care of anybody else. It's like they say on the airplane, put your mask on yourself first.
SPEAKER_01Yes.
SPEAKER_02You've really got to be the happiest, healthiest version of yourself to do this job. Because if you're not resilient and taking care of yourself, you're not gonna make it through those hard days. We've instituted a lot of programs. One is um a code green. So if you've if you've gone to a terrible call, I call them the dead baby calls, but they can be other other things as well. Usually dead babies are really hard to handle. We want you to take 30 minutes to regroup. We want you to call our on-call therapist. We want you to eat a sandwich, go to the bathroom, drink some water. Maybe go home and hug your own babies. Take care of yourself. Because if you don't take care of yourself in that moment, it'll just build up and build up. And the next dead baby call you go on, it'll be even harder. And then maybe you go to a suicide, and that's really traumatizing. Maybe you go to a fire, you hear people screaming, and you know you can't get to them. Those build up. The trauma that we see, the trauma that we experience builds up inside of us. And if we're not taking care of ourselves, if we're not going to see a therapist, if we're not exercising, if we're not sleeping well, if we're not drinking water. I know I keep coming back to water, but it's so important. We're like flowers. We need water. If we don't take care of ourselves, we can't take care of other people.
SPEAKER_00Tell us a little bit about the books you wrote and how you've tied this in to your particular path, or vice versa, how the path has tied into these books.
SPEAKER_02So in 2017, I um was in between jobs and decided to take a trip to Italy where I saw this animal in statues and fountains and mosaics. And this animal had two legs like a horse, two wings like a bird, and a fishtail. And my US cell phone wasn't working in Italy, so I couldn't Google what this animal was called. I later learned that this is called a hippocampus, which is the same word that they used for part of the brain. But I didn't know that it was used to describe this animal. And because I didn't know what it was called, I just made up a word using the Italian words for horse, fish, and bird, and mashed them all together and named this animal Ceppetcio. And I kept seeing these ceppecos everywhere, all over. And I realized that because Gippecho is a little bit like each of the animals, Gippeccio can teach them not to be afraid of each other and they can all play together. That night, something really terrible happened in Charlottesville, Virginia, where some people were killed. There was a lot of hate in the world in a way that I don't really remember it being when I was young. A lot of people were up late posting online about how they felt about it. I'm not on Facebook, so I spent the night that I was upset about it writing a children's book about how Geppetchou can bring everyone together. So a few weeks later, I was at the Yad Vashem uh museum, which is the Holocaust Museum in Israel, and I saw these Nazi-era children's books from the 1930s and 1940s teaching anti-Semitic values to children, teaching children how to hate. And that maybe I had written that book. So I typed it into the note section of my iPhone, and I emailed it to three people: my mom, my sister, and my best friend. My best friend is a pediatric emergency medicine, or I'm sorry, pediatric critical care physician. She and I went to Texas Children's Hospital uh for fellowship together. She is a devout Muslim. She keeps her head covered. She is um praised five times a day. I am a uh Jewish person who has been uh not very observant over my life. But she and I are best friends. Whether it seems like it should be that way on paper, I don't know. But she's a really incredible woman. And so I sent her this book, and it was more like, hey, this is what I'm doing this summer. Hope you're doing well, love you. She read it and sent it to her mom. And I knew that her mom was a volunteer for some programs that did reading for children affected by war. But what I didn't know was that that was the volunteer foundation arm of her children's publishing book company. So six weeks later, I received a phone call from a publisher saying, We've read your manuscript and we'd like to publish your book. And 12 months later, I had a copy of my book, Chepeccio and her flippity floppy floppy friends, where Cepecho teaches the birds and the horses and the sea lions that they don't have to be afraid of each other, that they can all play together on the beach. And I took that and went to schools and went to first grade classes, played the ukulele, and wrote some songs about Cepecto on the ukulele, and went to schools and I sang and I played the ukulele and I talked to them about acceptance and how we're all a little bit different and how we should embrace each other's differences. And I did that all the way until COVID when the schools closed. And I think sometimes, you know, maybe I'll go back and start doing little reading, reading and singing hours with students. I did some at libraries and things like that. But I think that really what I learned from all of this is that sometimes ideas can grow into something beautiful. And if you'd have, I mean, it started, it started with a moleskin notebook, the tiny one, the tiny moleskin notebook and a picture that I drew that I showed to my family, and they said, this is just for us. When we say this is just for us, it means this isn't good. Don't show this to anybody else. But sometimes an idea, even if it's just for us initially, can grow into something really beautiful and can, you know, at least in my mind, I'd like to think that my book has touched some people's lives and maybe taught some kids how to how to accept people who are different, or at least dance around the room and sing a song with me, which I guess is never a bad thing.
SPEAKER_00I'm gonna go out on a limb, but it seems to me that perhaps when you wrote this, there was a therapeutic element to this or an act of defiance. Is it tied to anything in your life particularly?
SPEAKER_02You know, I think I think that creativity is always therapeutic. Um I love kids. You know, I'm a board-certified pediatrician. I love things that kids like. And I do believe that reading is really important. And so I think that this was, I mean, it felt like something that just flowed out of me. I couldn't control it. I didn't sit down and say, I'm gonna write a children's book. I wonder what I'm gonna write it about. It was just something that I wrote, scribbled down into a notebook on vacation. And I do think that creativity is uh is therapeutic. And sometimes sometimes it just turns into something.
SPEAKER_00As we come to sort of the end here, what's a memorable achievement of your team that you'd like to share with the wider audience?
SPEAKER_02So I think that the biggest achievement for our team has been resiliency. Coming out of COVID together, coming out of January 1st together. But I think that the thing that's had the biggest impact is our blood program. Through our blood program, we've saved a lot of lives. People who would otherwise die from their injuries are out walking around and living their fullest life. But we didn't just affect the lives of the people in New Orleans. DC, Washington, D.C., Atlanta, and Philadelphia all copied our methods for our blood program. And Washington, D.C. has had a 30% decrease in their murder rate because of their pre-hospital blood program. So the work that we do at New Orleans EMS really influences the nation. And that's incredible. My team is phenomenal. They work hard and I would put them up against physicians in other places. They are incredible clinicians, they are exceedingly smart, they ask great questions, they save lives. And I respect them so much. And I am so grateful and so proud to work alongside them.
SPEAKER_00Dr. Marino, gratitude for being our guide in the world of emergency medical services, to the New Orleans Emergency Medical Service and all EMTs. Thank you for all you do. Thank you to the audience for listening. As your host, Maurice Brungart, I welcome you to join us again next week. And that you invite others to do also follow Brungart Law's Lang app, where we provide a little extra perspective because the devil is always in the details. Dr. Marino, again, thank you.
SPEAKER_02Thank you so much for having me.