Couple of book reviews

Apologies for the lack of posts lately.  Between a massive contract at the “real” job and having a ton going on in my offline EMS and personal lives, I’ve given the blog a bit less attention than it should have.

However, I’ve recently added several books to my EMS library that I believe the thinking medic should own.

The first is called Avoiding Common Prehospital Errors.  It’s a collection of short (2-4 pages) articles about various aspects of EMS care as written by various physicians, nurses, and EMS providers.  For the average EMS provider, especially those in the average EMS system, it’s a game changing book.  The book contains most of the recent science (published in 2013) out there and more importantly, each article is thoroughly cited with even more references.  If you’re looking to institute evidence-based medicine in your EMS practice, the book, with a few exceptions, does an excellent job of advancing science as opposed to dogma. As such, when the contributors share bad medicine in a few instances (naloxone for altered mental status and a slight dose of “backboard everyone” paranoia), these instances stick out like a sore thumb.  I still highly recommend it.

Virtually everyone in EMS has, at one point or another, had a field guide or pocket guide.  With the rise of smart phones, these are going the way of the dodo bird.  However, one field guide still stands out.  I cannot help but recommend Medic’s Little Helper.  While the book is Canadian, and as such, contains some metric measurements that US EMS providers don’t use, especially for blood glucose levels, it’s a thorough reference that covers a variety of topics in EMS from the most basic reminders all the way to the critical care arena.  It barely fits in the pocket of cargo pants, but it’s a useful companion to have.  Also, highly recommended.

When you’re managing risk….

After seeing some of the less stellar EMS providers out there, I can certainly understand why EMS systems and physician medical directors engage in risk management.  I would too and I encourage it.  EMS providers are great at reacting to medical emergencies and physicians, by and large, are great at medicine.  However, in my humble (ok, laugh) opinion, the professionals who know how to manage and mitigate risk are attorneys.

Several EMS systems attempt to manage and mitigate risk by creating an extensive field training/credentialing/clearance to practice model.  The lawyer in me is skeptical.  Allow me to throw out some legal analysis that I believe illustrates some additional risks that this paradigm creates.

1) Whether we like the National Registry or not, we can all agree that they’ve spent a great deal of time, money, and effort in producing a test that can be validated and defended. How many other organizations can defend their testing processes?  How many EMS systems can defend their field training processes?  I can assure you that this is an employment and/or civil rights case waiting to happen, particularly if adverse action is taken and you can show some discrepancies in how some people were treated versus others.

2) As we all hopefully remember from medical-legal 101, the standard of care is “what would a reasonable and prudent provider of similar education and experience do?” We also know, that generally speaking, Good Samaritan laws as well as other state-specific statutes often hold EMS providers to a willful conduct or gross negligence standard.  Assuming that you’ve created this extensive process to authorize a provider to function in your EMS system, I believe that you may have created a system where what might be ordinary negligence could potentially be considered gross negligence since they went through some extensive process that could be argued to hold them to a higher standard of care.

3) I think there’s potentially increased liability for the EMS system and the physician medical director.  Imagine this one well-placed question from a plaintiff’s attorney.  “So, you had this medic for X number of months.  And Medic So-And-So still made an error in calculating the drug dose.  What exactly was your system and FTO Such-And-Such doing during these X months of field training?”

4) While anecdote is neither law nor science, I could very easily imagine a case where a state licensed advanced provider who is not locally “credentialed” could be in a time-sensitive situation with a bad outcome. Imagine a pediatric seizure patient who did not receive benzodiazepines because the provider was neither equipped nor authorized to provide advanced care.  I can virtually guarantee that this family will be sympathetic plaintiffs and they will be able to find an expert witness who will testify that their child would not have suffered an anoxic brain injury had the first arriving provider been able to administer the proper medication(s).

Do I think that EMS systems should turn providers loose on day one?  Absolutely not.  I also believe that the field training process should focus on operationally integrating a provider into the local EMS system and that the appropriate way to develop providers medically is through the quality improvement and continuing education processes.  But then, how many EMS systems have developed these processes?

I believe a field training process needs to exist.  There are several strong, validated programs out there, most notably the EMS FTEP program out there.  Why reinvent the wheel when you don’t have to?  Combining a strong, proven FTO process with a rigorous QA/QI process and ample opportunities for continuing education and professional development is my recommendation for real EMS risk management.

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