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 provide EMT-Intermediate, oops Advanced EMT (showing my age) and paramedic level care.  I’ll still comment on that, but in terms of ATCEMS’s model being an example of one of two extremes of the EMS field training or credentialing process.

This cartoon/meme has been making its way around EMS social media and has popped up on my Facebook feed more than once already today.

Having been in EMS for roughly 14 years now, I’ve seen a variety of methods of providing field training.  They run the gamut from “here’s the keys” to “you’re repeating your paramedic clinicals with us for the next six months.”  As with anything in EMS, we run between two extremes and rarely find the “Goldilocks” point of being just right.

In some EMS systems, the FTO and credentialing process exists in name only.  At one unnamed EMS service, my official FTO process consisted of one ride with a field training officer for twelve hours.  Since I’d been off the truck for a while before starting there, I asked for more time before I even got that.  I got a shift before that where I was officially riding as a third crew member, until the paramedic FTO didn’t show up. Combine that with a chest pain call and the EMS director showing up on scene and asking if I was comfortable with taking the patient 40 miles and my field training process existed primarily on paper.  Of course, when you’re at a rural service that’s already short on staff, much less advanced providers, a field training process seems like a luxury that you can’t afford.  In my opinion, that’s a risk management nightmare.  When a clinical (or operational) failure happens — and it will, the discovery process that a lawyer will engage in will expose these shortcomings and present them to a jury of twelve citizens who couldn’t figure out how to get out of jury duty.

Then, there’s the other extreme.  Let’s take a large, unnamed third service EMS system that’s had an extensive process for bringing on new paramedics.  For many years, that process consisted of several months of a new hire academy then a field training process of several more months.  In short, the process to become a paramedic in this system became a virtual repeat of paramedic clinicals. Then a different medical director came in and decided that there were “too many paramedics” and required new hires to function at a modified EMT level for one to two years before being eligible to “promote” to paramedic.  Let’s now throw in the dozen or so fire departments in the county that provide EMS first response. Ever since before I got into EMS, this EMS system was unwilling to credential first responders above the EMT level. That’s their prerogative. But don’t say you’ll allow it and then make a process that’s so obtuse and arbitrary that it’s a virtual impossibility to credential. The previous medical directors and the department’s clinical management created this mess and they’ve now given the fire departments the rationale to create their own EMS programs. In fact, said county (cough, Travis County, cough) just created its own medical direction to give the county fire departments the ability to run their own paramedic first response program.  And that doesn’t even include two of the fire departments that have created their own paramedic-level ambulance service.

There’s a saying in the law that those who seek equitable relief must come to the table with “clean hands.”  In this case, I have to say that neither party have clean hands.  The EMS system wanted to be the sole provider of advanced life support in the name of “patient safety” and other benevolent sounding reasons for turf protection.  The various county fire departments want paramedic first response and in some cases, transport, to justify their budget and existence and to satisfy the various firefighter union locals that want their members to be an “all hazards department.” In short, to quote Mel Brooks as the governor in Blazing Saddles, “Sheriff murdered! Innocent women and children blown to bits! We’ve got to protect our phony-baloney jobs, gentlemen.” Fire codes have dramatically reduced the number of fires out there.  In Texas, many of the fire districts are funded by property taxes. Also in Texas, there’s a healthy skepticism of government and taxes.  Without EMS call volume, many citizens would wonder what they’re paying a fire department for.  Personally, I’d have much less heartache about the county’s decision to provide its own medical direction for the fire departments if this outcry for separate medical direction had been occurring for years, rather than over the last couple of years that have also been associated with the virtual elimination of volunteer response in the county and the addition of a second tax district in some of these fire districts to “support EMS.” If I feel for anyone, it’s the current medical direction of the EMS system.  They’re passionate about good medicine and supporting the practice of good prehospital medicine.  They’re also in the unenviable position of fixing a system that believed its own public relations for too long and had frayed, if not outright violated the trust of its supposed “partner” first response agencies.

So, what is the happy medium for field training and bringing on new people?  I don’t have studies or statistics to support my general concept of what works.  What I know doesn’t work is handing someone the keys to the controlled substances and saying “Good luck.”  But I’d also question the value of a lengthy process that is a virtual repeat of paramedic clinicals.  In theory, the certification exam for initial certification should provide some assurances of entry level competence. (That in itself is an argument for another day.)  In my ideal world, I’d argue for a field training and credentialing process that is competence based, rather than based on calendar days, clock hours, or getting a certain magic number of certain patient populations.  And in some cases, we’re rarely going to see certain patients in the field.  That means access to a skills lab and/or simulations and scenarios. The process should focus heavily on the unique clinical aspects of that particular EMS system, whether in regards to airway management, medications, or other uncommonly encountered interventions. The process also needs to focus on the operational aspects of being a provider in that system. How many of us haven’t been taught which channels/talkgroups are on our radios?  That, along with resupply, fueling, and documentation requirements often get overlooked in the FTO process. As much as we need to ensure clinical competence, we also need to ensure that a new medic (at any certification level) in the system knows what’s supposed to happen to make good patient care happen.  And let’s not even discuss transport destination determination, which is regularly overlooked.  Getting the right patients to the right hospitals is a core function of EMS and neither initial EMS education nor the processes to bring a new provider into an organization usually address this.  As a result, we routinely end up taking critically ill patients to hospitals incapable of caring for them.

I’ve ranted for a while and I appreciate the indulgence.  The short version is that, like much of EMS, field training and bringing new providers on board a system is a collection of bad practices and extremes. We can do better.  Both our profession and our patients (aka: customers) deserve it.

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