What does the patient/client want?

I’m trying to put some complex and jumbled thoughts into words here, so bear with me. As some of you may know, I’ve dealt a ton with health issues for various family members over the years, especially over the last few months. One thing that I’ve seemed to notice is that too many people in healthcare think they’re helping when they’re substituting their own wishes and priorities for that of the patient and their loved ones. Further, many professionals in both medicine and law forget that the patient/client and their families have a life outside of and in addition to the matter currently being addressed. The outside world rarely pauses and often refuses to pause so that a patient/client or their family can reschedule the outside world at a moment’s notice all because someone feels that their little niche or agenda has to be addressed right this minute.

As a result, the patient and their family feel that the providers of all kinds, whether physician, nurse, therapist, or case manager, are dictating to them rather than caring for them. It can easily make the patient and family feel as if they have no control over matters relating to their care. Example: “You have to be here for a very meeting. Today.” Reality: Here’s the same discharge plan that we’ve been discussing for several weeks. 
 
People often feel an absolute loss of control of their care and their wishes. And when people feel they’ve lost control of their own affairs and that their wishes aren’t being heard, they’ll find another way to ensure they’re heard, whether in court or in filing a complaint with a regulatory agency. The nature of our healthcare and legal systems being what it is, the courtroom or administrative complaint is the only way that some clients/patients and their families feel that they will be heard.  (Free legal advice: it takes a lot less time and money to be nice up front and explain things early than it does to answer a lawsuit or an administrative complaint.)
 
Part of being a professional is in recognizing that the patient/client still maintains autonomy – the right to make their own decisions. Your job is, within the confines of the law and ethics, to help that patient meet their stated needs and goals. Being a professional means giving a patient/client the services and all of the information they need to make a good decision, then abiding by that decision and putting the patient/client first.  Heck, even as a lawyer, clients go against advice all of the time. Look how many criminal defendants insist on testifying in their own defense.  Look how many DWI suspects agree to take field sobriety tests and take the breathalyzer, even though they’re basically giving the evidence to convict themselves.  As I like to remind professionals of all sorts, people have the right to make bad decisions.  Fundamentally though, as a professional, we exist to provide services to our patients/clients in accordance with their wishes. 
 
This should ring true whether it’s medicine or law. And it’s a good prescription for limiting your involvement with lawyers to represent you. As another EMS colleague of mine says, “We can suggest, but forcing patients to do what they don’t want buys lawyers nice cars.”

“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 … [Continue reading]

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

Here's a great example of what's wrong with EMS. This morning, I was looking at the webpage for the EMS For Children Improvement and Innovation Center project being administered by Texas Children's Hospital. The webpage identified twenty-eight staff … [Continue reading]

Thoughts From The Sidelines

After EMS Today last week and dealing with some family medical issues, I have a few thoughts to consider. EMS is the practice of medicine.  It always has been and always will.  As such, we owe it to our profession and our patients to focus not … [Continue reading]

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]