“Dr. Dunning, I presume?” said Mr. Kruger.

An ongoing topic of discussion on EMS social media is the Dunning-Kruger Effect.  Wikipedia defines the Dunning-Kruger Effect as “a cognitive bias wherein people of low ability have illusory superiority, mistakenly assessing their cognitive ability as greater than it is.”  Over the past few days, I’ve seen some great examples of EMS’s collective Dunning-Kruger Effect.  I also call these moments “not knowing what you don’t know” or “doubling down on dumb.”

The greatest exhibit that I can present to illustrate EMS’s exhibition of the Dunning-Kruger Effect comes from a self-promotion post by a critical care transport educator.  This educator, while promoting a post from JEMS about a Texas EMS system’s decision to adapt their protocols to prevent ventilator-induced injuries, breathlessly exclaims “ICU care begins in the STREETS! i expect my medics to be BETTER than EM and ICU attendings. ALWAYS. Period.” (Note: capitalization error was taken directly from the posting.) In the spirit of self-promotion that afflicts so many EMS “celebrity educators,” the post goes on to promote his recent conference appearances where he discussed using ultrasound to identify lung injuries and adjust ventilator settings.

Here’s the thing.  I don’t know how good or relevant his presentation is. And we all have to make a buck. And if you don’t promote yourself, no one else will.  But there’s probably not a single paramedic out there who’s better than an attending emergency medicine or critical care physician/intensivist.  Having said that and having my own experiences to guide my opinions, I will say that there are many paramedics who can assess a patient and rapidly treat a critically ill patient better than a physician without emergency medicine or critical care education.  Heck, that’s the  primary purpose of critical care/retrieval/flight paramedicine. When a patient is critically ill in a remote setting or an outlying hospital without specialist resources, that’s why you have critical care transport capabilities.

And yes, a critical care medic is probably better than an EM/ICU attending at certain technical skills.  Notice I said skills.  Most physicians don’t deal with vent settings.  Why?  Because in an ICU setting, there are others to help with such things. The physician has their eye on the big picture.  General Patton might not have been the tank driver than an individual sergeant was.  He didn’t have to be.  He did have to know exactly how to rout the enemy on the battlefield and accomplish large objectives.  Similarly, a HVAC technician probably knows more about fixing a faulty air conditioner than does a mechanical engineer. But I can almost guarantee you that the mechanical engineer knows more about how a HVAC system works and fits into a larger picture than a technician does. Likewise, I have a good friend who’s a state trooper.  I can assure you that he’s better than me, a lawyer, at knowing the intricacies of DWI law.  But he’s probably going to have a harder time putting all of the law together to get a complete picture.  Technicians, like many of us in EMS, excel at particular technical skills, hence why they’re technicians.  Professionals excel at the big picture, synthesizing multiple sources of information, acting on said information, and leading a team to solve that problem, almost like a conductor leading a symphony orchestra. (Heck, in the emergency room, look at how a resuscitation is run.  The leader, usually a physician, is rarely performing skills, but rather leading others in what needs to happen.)

Yep.  EMS often illustrates the Dunning-Kruger Effect with our belief in our own expertise.  But I can’t completely blame us.  Over the past few days, I’ve also seen ham-handed attempts by EMS educational programs to engage in education on EMS social media that illustrate President George W. Bush’s infamous question, “Is our children learning?” One community college based EMS education program shared a viral news video of a police officer being administered Narcan for an “exposure.”  Unfortunately, the initial posting by the educational program was posted without context and showed a breathing police officer being administered Narcan for a possible exposure to a stimulant, most likely methamphetamine. As even the lay public is learning, administration of Narcan is indicated for respiratory depression secondary to an overdose of an opiate/narcotic.  In other words, a conscious, breathing patient doesn’t need Narcan.  And an EMS educational program should definitely know better.

But that may not be the worst.  Late last week, a nationally known bachelor’s degree program in paramedicine shared a guest blog post from one of their students. The article was about the controversy of allowing paramedics to intubate.  Well and good.  The topic is definitely worthy of further discussion, especially considering the limited access that many EMS education programs have to clinical sites for live intubation practice. Yet, the article soon disappeared from that college’s social media.  Namely, many EMS providers pointed out multiple misspellings in the post along with dated studies cited (the most recent was over ten years old) and the lack of mention of high-fidelity simulation or more recent science supporting safe intubations through delayed sequence intubation by EMS providers.  Presumably, this blog post was reviewed and approved by the college’s faculty prior to going live. Sadly, when this kind of writing is presented by an educational institution, the writing serves only to reinforce negative perceptions of EMS by the rest of the healthcare community and remind them that the “ambulance drivers” aren’t yet at the same level.

The truth is that EMS does a good job at its core mission.  We excel at providing urgent and emergency care in the out of hospital setting and using a public safety skill set to do such. Our knowledge of the medical field is an inch wide (unscheduled out of hospital care) and a mile deep in that field.  Let’s own that field for ourselves and quit trying to prove how smart we are.  Inevitably, when we stray too far afield and when we keep calling attention to ourselves, we too often illustrate the Dunning-Kruger Effect.  These moments don’t advance EMS.  On the contrary, they remind us why everyone except for EMS providers get to make decisions about what happens to and for EMS.

 

How To Create a Paid Fire/EMS Department

As of late, I’ve posted a fair amount about the local politics involved with the various tax-funded emergency services districts in my part of Texas basically ending volunteer participation. Truth be told, I definitely think there’s some shenanigans from paid staff and their union locals. But folks, if we’re going to talk about the end of volunteer participation, we need to take a long hard look at the volunteer culture.

As I often teach through sarcasm, I present the following recommendations for ways to ensure that your volunteer department becomes a combination department and eventually a completely paid department.

  1. Run the department as your own private social club.  By gosh, this is a place for the connected locals to hang out, use as a private lounge, and maybe go travel on someone else’s dime.
  2. Training?  Why do it?  And if you do feel you have to do it, focus on cool, fun stuff instead of the basics of being able to operate at a fire, rescue, or medical call.
  3. Membership? Who needs that?  If people want to join us, they’ll find us. And if they do figure out how to join the department, ensure that the process is all about who you know rather than what you’ll bring to the department. And if you do a membership drive, make it a joke.  Either try to recruit “heroes” (as opposed to members who want to help others) or do the same tired routine that you do every so often and then claim “nothing’s working.”
  4. Speaking of what you bring to the department, always make sure to turn down free help. If the person can’t make the arbitrary number of meetings or responses, or lives “too far,” don’t show any flexibility.  If you’re a combination fire and EMS organization, be sure to turn down someone only interested in one discipline. It’s not like having an extra medic frees up a firefighter or vice versa.
  5. Accountability and transparency is for the birds.  You’re heroes!  There’s no need to justify your budget or be accountable to those politicians at the county or the city who “don’t understand what we do.”
  6. Speaking of budgets, let’s be sure to spend like drunken sailors on shore leave. Buy those big-ticket, rarely used capital expenditures regularly, then run around scavenging for IV needles and working radios.
  7. Responses?  We’re volunteers.  We don’t have to go to a call if we don’t want to.  And we sure don’t go to “old so-and-so’s” house or the local nursing home.  It’s not like they really need help. And especially if you have paid staff working with the volunteers, there’s no need to go to all calls, only the fun ones.  And if you show up on the fun calls and don’t get to do “fun” stuff, by all means, complain loudly.
  8. Uniforms?  They need to fall into one of two extremes.  Either no uniforms and look like “People of Wal-Mart” or uniforms that make you look like an Italian Field Marshal.  No need for things like photo ID cards, t-shirts, polo shirts, and jackets.  It’s either the Redneck Yacht Club or the full parade dress.
  9. Be sure to remind new members that they don’t know how “we do things around here.”  Be especially unwelcoming to experienced people who have significant prior experience.  It’s not like they bring anything to the table.
  10. Don’t create strong relationships with the other members of the public safety team.  No need to play well with the surrounding fire or EMS agencies, much less law enforcement.  It’s not like you’ll ever need any of these guys again.
  11. And if you have a state organization for volunteer fire and EMS, don’t join it.  And if you do end up joining said organization, ensure that your organization is quiet at the state capitol.  We don’t want to antagonize the paid guys or advocate for volunteers.

So, if you follow my  program, what will you get?  Simple.  Eventually, the taxing entity and taxpayers will tire of your antics. They will point to your lack of training, transparency, fiscal responsibility, and shrinking membership roster.  First, they’ll bring on a small duty crew during the day to “supplement” the volunteer staffing.  Eventually, that supplement supplants the volunteers.  And somewhere during this process, your department becomes absorbed by the taxing entity.  Congratulations! Your non-profit volunteer group has now become a fully paid local government department.  But of course, the fun only begins.  All of the time and effort that you could’ve spent on having a functional volunteer or combination department can now be spent on lengthy political and legal battles over who gets the property from your department.

This story repeats itself over and over again, yet we don’t seem to learn.  The average volunteer emergency services provider is often their own worst enemy and the biggest reason why departments go “professional.”

And so it goes.

Cleared To Practice, AKA: The License To Kill

I booted up the computer fully intending to write a long screed, aka rant, on the issues currently facing Austin/Travis County EMS, its medical direction, and their relationship with the multiple county first responder agencies and their ability to … [Continue reading]

EMS is OUR Profession

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Thoughts From The Sidelines

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Couple of Quick Thoughts

While perusing social media this morning, I noticed a couple of things that bear repeating.  Again. The same professional EMS committee members are now taking public input on "EMS Agenda 2050." yet we can't always even get the core mission of EMS … [Continue reading]

It’s Not EMS Abuse; It’s EMS Use

There’s a lot of talk about “EMS abuse” by EMS providers. I’d submit there’s a lot of EMS “use.” We’ve done a good job of telling people to call 911, but we’ve failed in telling them what an emergency is, what EMS is, and what EMS can do for … [Continue reading]

Stay In Your Lane

Years ago, my parents called the same plumber anytime they had a plumbing issue.  Norman the plumber knew all about plumbing. Norman didn't claim to know anything about carpentry, electrical work, or appliance repair. Norman didn't claim that with a … [Continue reading]

A Couple Of Reviews

In the spirit of keeping up with my professional responsibility to keep my paramedic certification up both for National Registry and Texas, I've been attending some continuing education lately.  As such, I thought I'd pass on a few comments about … [Continue reading]

All Politics Is Local: Or an EMS Labor Union and the Kerfuffle

There’s been a lot of discussion on EMS social media about the contract between the City of Austin and the Austin/Travis County EMS Employees’ Association (AKA: The Union) lapsing. I’m not a medic for ATCEMS, but I feel compelled to wade in as an … [Continue reading]