Doing The Right Thing

Last week, several EMS friends and colleagues asked me to look at the recent Kentucky case on EMS liability. Obviously, as a lawyer, my first and foremost answer is always going to be “it depends.” I’d also remind you that even appellate cases are incredibly dependent on the facts of the underlying case and the law in the relevant jurisdiction. If you’d like an in depth analysis of the case or how your organization can learn from this case, get in touch with me. I answer legal questions for a living, ya know?

Having said those disclaimers, though, there are a few things that stand out to me and bear discussion.

First and foremost, it’s quickly glossed over that the medics in question didn’t check their monitor and possibly not even their equipment. There’s no record of the daily check on either in this case. And the monitor failed to defibrillate when it needed to. As my torts professor at Texas Tech University’s School of Law used to remind us, “If there are damages, you must pay.”

Second, the court does an in depth analysis of the medics using the Active 911 phone app to navigate (incorrectly, no less) to the call when the policy manual for the department requires the use of the map book. By operating outside of department guidelines, the medics lost their qualified immunity at least under Kentucky law, under this set of facts. More on that to follow. I’d note two things, though. First, especially in rural or rapidly growing communities, maps are remarkably inaccurate no matter the source. Second, while I don’t have the trial transcripts, a good lawyer might have developed testimony to state that the Active 911 phone app does indeed constitute the use of a department approved map. Active 911 isn’t something people can just randomly download. The department has to subscribe to the service and it’s typically integrated into the Computer Assisted Dispatch (CAD) system.

So this all leads up to a long standing belief I’ve had — and it covers both the mapping issue and the equipment check issue. Namely, if you make it easier to do the right thing, people (typically even including your worst EMS providers) will do the right thing.

Over the years, I’ve encountered many such policies and processes that make it difficult for field providers to do the right thing — to the point that people either don’t do the right thing or don’t do anything at all. I’ll illustrate with a few examples over my nearly twenty years as an EMS professional.

Case # 1 – rural EMS system is worried about compliance and creates lots of policies and processes. One of those processes is to go with a system called Operative IQ for truck and bag checks to be completed at the beginning of each shift. Operative IQ in and of itself isn’t a bad platform. Like any IT solution, it’s all in the implementation. But this truck and bag check takes nearly 45 minutes — and double that time if there’s a spare truck quartered at your station. In other words, guess how many medics did a proper check of 45 plus minutes versus clicking through most things except the ones they deemed important or that required an actual number to be entered?

Case # 2A – As I call this, this is the story of the bags. I was at one rural EMS service that had a large Thomas pack on every ambulance. This was probably the heaviest bag I’ve ever carried in my EMS career. (Heck, if you want to use this bag for a physical fitness exam for new or current employees, let me know. I can hook you up with their chief.) The bag had a full assortment of trauma supplies, a D cylinder of oxygen, various oxygen masks, a complete set of intubation supplies, assessment supplies, and a full panoply of IV supplies. In other words, the bag had everything except one thing. Namely, any medications at all. Where were the medications at this service? Well, they were in a cabinet in the ambulance. Loose. (Except for the small amount of controlled meds which were in a small metal lockbox.) Again, guess how many crews took in the bag? Virtually none. To the point that the bag rarely even got checked. (By the way, did I mention that there wasn’t even an inventory or stocking list so you’d know what you’re supposed to have?) All but the least informed and laziest EMS clinicians know that it’s usually best to bring the gear to the patient and try to stabilize before transporting. But when you have a bag that makes it impossible to do so, you end up with 2 alternatives, both of which are bad. Option 1, just take the stretcher and get the patient in the ambulance. (At this service, this was VERY common with the BLS crews, who’d often resort to the funeral home days of EMS with throwing the patient on a stretcher and driving fast.) Option 2 was to bring in the Thomas pack and go back and forth to the ambulance getting the medications you needed from the shelf. Insert your favorite Benny Hill or Keystone Cops clip there.

Case # 2B – This is how you do it right. I worked at an EMS system on the far outskirts of Houston. They had their challenges – namely, try being the third crew member at a station with only two bedrooms and virtually no options to eat away from the tiny kitchen in the station. But the one thing they perfected was their bag design. First, the cardiac monitor’s pouches also held aspirin, nitroglycerin, and a glucometer. There was a trauma bag with everything to manage a traumatic injury (aside from pain medications) from bandaging and splinting supplies, IV supplies, “Stop the Bleed” type devices, and some basic assessment supplies. There was also a pediatric bag with the pouches color coded with the Broselow tape colors. But my absolute favorite was what they called the “ALS bag” that went in on every call. The bag had IV supplies, airway supplies (including endotracheal tubes and iGel devices), and medications. Better yet, the bag had two plastic cases in them. One was a case with all of the medications and supplies needed to handle an allergic reaction up to and through anaphylaxis. The other case (of a different color) had all of the medications and supplies to handle a hypoglycemic emergency. Finally, the spare medications in the ambulance were in a bag that could easily be removed from the shelf to handle an extended resuscitation or to treat a patient who needed more medications. In short, there was no reason you couldn’t bring the right supplies right to your patient each and every time. Oddly enough, while this service had its challenges, not bringing gear to the patient’s side was rarely, if ever, an issue.

Case # 3 – There are volunteer EMS organizations that issue bags (stocked at the appropriate certification level) to their members for them to respond to calls. That’s a great idea especially in areas where an EMS response may take a few minutes. But if you issue out bags and supplies to people, they need to know what they’re supposed to have AND be able to get the bag restocked without significant heartache or hassle. Otherwise, you end up with members either responding without the items they need to care for a patient or they don’t respond at all because they don’t believe they have what they need to respond. Anecdotally, we can see those things happening either by runs made by members or when a member turns in a bag that’s chock full of expired supplies and medications. How do you fix this? Step one is to make it easier to access the supply room. Step two. Organize the supply room and make the supplies easy to find. Bonus points if you have eager leadership who has taken ownership of the supply issues. Extra bonus points if the supply room now has all of the items that were on back order for eons now easy to find. (The gentleman I’m speaking of is my current EMS hero for this.) Step three. Make the supply/stocking list easy to access. Said current EMS hero recently made the organization’s protocols easy to access via a phone app — and the app includes the supply list for the bags. Speaking purely hypothetically, I know of at least one attorney/paramedic who now has a bag stocked to specifications and with the current meds.

In summary, most people are in emergency services, public safety, or healthcare because they want to help others. And most of those people know that they need to do the right things in order to help others. Most of us also have a relatively low BS tolerance. What does that mean? Procedures and policies that don’t work get ignored or there’s malicious compliance. That undermines respect for the organization, the leadership, and the procedures and policies that DO work. Further, when the bad thing happens (and it will), the lawyers have a field day. Even if the actions (or inactions) of these providers didn’t cause the bad outcome, there’s enough doubt to give a jury (or an insurance company) reason to question what really happened. It’s also a huge hit to the department’s reputation and the profession’s reputation as a whole.

For the leaders (whether formal or informal) in organizations, take a good look at your policies, procedures, and processes. See if they reflect reality. See how much of a “BS factor” there is to each and every one. Revise or even remove the ones that don’t make sense. And when you finally get to something that’s workable, hold people to account. Even if there’s not a negative outcome. Especially if there’s not a negative outcome. As we know, “just culture” doesn’t look at the outcome, it looks beyond that. On that note, when you bring someone in to talk about a violation, ask how and why it happened. Don’t immediately assume malicious or malevolent intent. The explanation might actually solve an underlying problem that you were never aware of. If it’s a department fault, fix it. If it’s an individual fault, remediate them or use the appropriate discipline. A policy that’s unenforced or not applied is a policy that a plaintiff’s lawyer will have a field day with.

As for those of us who aren’t in a leadership role, we need to let leadership know when something doesn’t work. Better yet, have a proposed solution. Hopefully, you’re in an organization that will take action on your concerns – whether making changes or providing insight as to how/why the changes can’t happen — or the current system actually works.

If you’ve made it this far, thanks. If I can be of help to you or your organization, I do make house (or station) calls.

Texas EMS Conference 2023 Postmortem

Well, it’s the week of Thanksgiving and for most people that means
turkey.  For me, Thanksgiving has always been stressful – mainly due to
family issues.  But therapy has helped with that.  (Mostly kidding,
y’all.) For me, this week has always been about the Texas EMS Conference and
all that means.  This is my nineteenth year taking care of Texans, first
as an EMT and now as a licensed paramedic. (For those of y’all reading this who
aren’t from Texas, the licensed paramedic thing is one of those weird Texas
differences – just like no beans in chili. For Texas EMS, we’re also special in
being a true delegated practice state and have no state protocols or scope of
practice.)

This has been one of my best years at conference ever. There were a couple
of minor lowlights.  The keynote speaker was a very generic motivational
speaker you could hear at any corporate conference, but I suppose that’s okay
too.  Also, lunch on Monday could’ve been better.  (Food wise,
there’s a really strong, albeit underrated, BBQ option just around the corner
from the Austin Convention Center.

2023 has been a year of growth and change for me in both my legal practice
and my EMS passions.  Being at the Texas EMS Conference has really brought
some of those changes home to me.

First and foremost, I am coming to recognize my own worth to this profession
based on my experience and education. Case in point.  I had a good friend
come to me about the challenges they’re facing at their department and
describing the recent promotional process.  (For what it’s worth, I think
I did pretty well on the exam questions.)  The discussion then changed to
a part time position with that department and where and how I’d fit in. Not
that long ago (maybe even six months ago), I’d have started working out the
details of a start date and such.  Not this time.  First and
foremost, I’ve got two excellent EMS homes that are giving me room to grow
personally and professionally with the goal of helping both of these
organizations get even better.  Second, I don’t need to drive a
significant distance if I really want or need to get on an ambulance. I
explained exactly that.  If they want me to come on board, it’s going to
involve me helping them advance and progress doing the things that I can do
that maybe their current staff doesn’t yet excel at – risk management,
education, clinical management, training, and organizational development.
I’m rapidly approaching the point in my EMS journey where the opportunity to
lead, advocate change, and develop my colleagues is what drives me much more
than running calls. In the spirit of full disclosure, I STILL love running
calls – even more so if I’m with a newer provider.  Watching them grow and
learn is as fulfilling as getting a good call, just in a different way.

The conference has also brought more personal recognition of my changing
roles in my EMS career. I attended classes that were directed to my roles as
the opportunities arose. I’d have never thought that I’d attend or enjoy a
class on electronic charting software. But the class couldn’t have come at a
better time as I’m evaluating software choices at one of my departments. It was
a huge confirmation when the issues I’d identified and been working through on
my own. Attending classes like that and learning about other topics that I want
to bring back to my departments gave me a whole new understanding of why chiefs
and officers attend conferences. It’s not about getting a vacation or about
taking the opportunity away from the field staff.  It’s for us to learn,
network, and bring back things to the entire department. Sometimes, with
limited budgets being what they are, the best return on investment is for
leadership to attend to improve the entire department. Now, whether the leaders
return with relevant knowledge to make better decisions for their organization
or share that knowledge with their team is an entirely different story.

This week has really helped me realize how my EMS experience is changing,
and I think for the better.  During the conference, two EMTs from one of
my departments reached out to me with questions – one about how to document a
call and the other based on information they learned at conference.  After
the second one of these, I realized I’m now (whether officially or
unofficially) the one that gets the call when there’s an issue.  (And
there’ve been other calls/emails/texts this past year along the same lines.) In
other words, for better or worse, I’m feeling that my new roles now mean I’m
one of those people who get the call when something unusual comes up, whatever
the issue.  The recognition from others has been both humbling and
flattering.  And just as we feel unsure of ourselves as a new provider,
the feeling of imposter syndrome is even more intense as a leader, whether
official or unofficial.

Being a leader – or identified as one – means you feel different or at least
you should. Getting that email or text about an uncovered event gives me a
bit more of guilt than it used to.  And the “level zero” page has caused
me to change clothes and load my car up to go out and work.  If you’re not
feeling that same sense of obligation or responsibility, maybe a leadership
role isn’t right for you. Being out in the field, helping shoulder the load,
and setting an example by being present is what being a leader is about. Any
leader who doesn’t get that is no better than the volunteer EMT or firefighter
who’s just there to get the t-shirt.

I really felt the change in my age and role on Sunday – which is typically
the day that most of us wander around the conference exhibit hall to get free
pens and swag while we catch up with people we haven’t seen since the last conference.
Sometimes, we actively avoid some of the people we haven’t seen since the last
conference. Especially this year, I managed to rebuild a few bridges I might’ve
burned over the years.  I like to think
that those of us on either side of some of those arguments both grew.  At least, that’s what we told each
other.  But what really made me realize
my growth came from a new EMT I know who’s likely coming on board with one of
my departments. Like me, she’s a bit older and is going to volunteer while
deciding if EMS is the right path for her, including the possibility of
paramedic school. She asked if she could come up to the exhibit hall to hang
out.  I remember that same eagerness (and
I try to keep it going for both me and others) and encouraged her to come hang
out.  I made sure to introduce her to all
of the people I’ve known over nearly 20 years in and around EMS.  She’s already scheduled for a ride along with
a large urban third service EMS system as well.
She commented on how many people I knew and how willing I was to
introduce her around.  It’s called paying
it back.  And if you’re not doing it, you’re
part of why so many in EMS are worried about where the next paramedics and
paramedic leaders and educators will come from.

When I first got started in this field, I heard a lot of jokes about the people
who wear their uniforms to conferences.
And I assumed they were yahoos, yokels, and every other slang term for “Rescue
Ricky” out there. I made sure to avoid that by and large over the years. While
at our Texas conference this year, I noticed how many folks WERE wearing
uniforms or at least their department polo shirts or job shirts.  More importantly, some of these people were
presenting. And quite a few other people were walking around the conference
looking perfectly normal.  Having said
that, though, not everyone needs to wear a full dress uniform reminiscent of
Idi Amin.  If you are going to wear some
of your department’s uniform, whether fully or partially, wear it in a way to
reflect the obvious pride you have in your organization.  Tuck the shirt in.  And don’t be passed out drunk in the
uniform.  As for me?  I finally broke down and went ultra casual
the last day – jeans, a polo shirt, cowboy boots, and the zip up fleece from one
of my departments. I will draw the line at a radio, pager, utility belt, or a
dress uniform more suited to a Park Avenue hotel doorman.

My lecture on Monday confirmed that I’m on the right path.  While some of my usual conference friends
came, I couldn’t think of higher praise than seeing one of my current chiefs in
the room along with a former battalion chief that I used to argue with like
cats and dogs. That vote of confidence in my knowledge and my abilities spoke
volumes to me.  I hope I found myself
worthy of that trust. I’m just glad that I’ve been able to, at least in part, use
both my legal education and EMS experience to demystify some legal concepts and
give practical advice to EMS professionals and agencies.  FYI, I’ll travel.

Here’s hoping that conference was as rewarding for you as it was for
me.  And if you’re in EMS and haven’t
been to a major conference, it’s past time to go – and learn outside of your
own department.  On that note, some of
the best learning happens outside of the classroom sessions when you get to network
with others and see what others are doing.

 

Why Can’t We Get Perfect Volunteers?

Earlier this week, I watched a great documentary movie about the volunteer fire (and EMS) service called Odd Hours, No Pay, Cool Hat. The movie does a great job illustrating the various cultures of volunteer emergency services throughout the country as well as people’s motivation to volunteer and why they remain. As a volunteer myself (almost 19 years now), I saw a lot of myself in the movie and recognized some of the people I’ve worked with, even if the names and locations weren’t the same ones in Texas that I know.

Then, I looked at one of the departments they highlighted. Said department (which is NOT in a poor or rural backwater) wants their members to do a weekly night shift and a 24 hour Saturday shift every 4th week. That kind of schedule isn’t a volunteer schedule. It’s a part-time employee schedule. While this department was along the mid-Atlantic Eastern Seaboard, I’ve seen several volunteer fire and EMS departments in Texas that operate along the same scheduling concept. And the department that I spoke to in Texas seemed genuinely offended that I wasn’t able to meet their 48 hours per month commitment via a twelve hour shift weekly as opposed to my suggestion that I could come for two 24 hour shifts on the weekend. Apparently, at least there, they had a surplus of Texas licensed paramedics willing to work for free.

What I routinely see is the self-fulfilling prophecy that “we can’t get volunteers.” The truth is that volunteers are out there. The truth also remains that not everyone has the time, temperament, or inclination to basically work a part time job — especially with the added burdens of attending monthly meetings, fundraisers, committee meetings, and various mandatory trainings only offered at certain times. Even more so if you’re driving a way because of limited (or no) opportunities to function as an EMS provider or firefighter nearby.

Even the “hiring” process at volunteer organizations can be haphazard. People often don’t know that an organization exists, let alone is looking for volunteers. And attending a few “business meetings” to be voted in as a member, whether it’s a pro forma vote or a popularity contest undermines the notion that a volunteer department is truly staffed by “unpaid professionals.” Attending some department’s monthly meetings also demolishes that notion as you witness the lack of accountability, personal politics, self dealing, sense of entitlement, and rampant spending on pet projects. Thankfully, these are not issues at either of my current departments (one combination department and one entirely volunteer organization), but the stories ring true nationwide when my volunteer (and former volunteer) fire and EMS friends discuss their experiences. And those are just the issues that arise at the business meetings — not even addressing training, equipment, operations, and the other day to day issues that will either cause people to remain long term members or rage quit when the final straw breaks the camel’s back.

Volunteer fire and EMS is often its own worst enemy as it lowers standards, engages in petty politics, and creates a self-fulfilling prophecy of not being able to find volunteers. Oftentimes, they can’t fund volunteers because people don’t know they’re looking. Or if people do express an interest in volunteering, they are turned away because the volunteer organization only has one way to use them, whether it’s the failing model of the fixed duty calendar (see also: You’re working as a part time employee at this point and you should be paid as such.) or the idea that one must be all things to the department to be of any use. (See also: Most volunteer fire departments that turn away EMS-driven individuals. Pro-tip: Giving an “EMS-only” EMT or paramedic the keys to a squad truck means those who want to fight fire can do exactly that.) And of course, once a motivated member makes it through the malarkey and is still motivated, they’re all too often met with the conundrum of command staff playing the martyr, yet who are unwilling to delegate anything. The idea that new members need to pay their dues seems in direct contradiction to the martyr mindset of many chiefs and officers who simultaneously bemoan that the younger generation doesn’t want to help while also retaining their positions and duties even longer than some United States Senators. (For example, take a look at the interlocking boards of most of the EMS organizations and “stakeholder” panels where board members and stakeholders haven’t been on an ambulance or fire apparatus since there was a BioPhone and MAST trousers.)

Until we stop chasing the perfect volunteer and take what’s available to us, we’re doomed to the volunteer fire and EMS model being a historical relic that will, at best, limp along only because of the unwillingness of local governments to adequately fund emergency services. While we still have a volunteer or combination model for emergency services (by the way, there are reserve police officers too, even in large agencies), we have to either adapt our organization to reality or adapt the prospective volunteers to the organization. The former will be easier, no matter what the old guy in the back of the meeting says.

Otherwise, the stagnation will continue with the duty roster becoming more and more empty and no one wanting to “put up with that BS” to “work for free.”

Blunt Talk

I was discussing some issues with some EMS friends online this afternoon and the topic of physician and nurse involvement in EMS practice, policy, and regulation came up — and how physicians and nurses seem overrepresented when EMS policy is being set. The challenge is that while most of these physicians and nurses know more medicine than we do – we know more about how to deliver medicine in a non-clinical setting.

The overwhelming majority of people in EMS aren’t invested in their profession. (See also the posts regularly occurring on EMS social media asking basic questions about topics such as how to recertify. But that’s another rant.) And since they aren’t invested, they don’t care or do anything. Those that are invested rarely understand how to fix or change things. Sharing trivia and/or virtue signaling from Med Twitter and talking down to others is counterproductive. (In other words, “you’re a bad medic if you didn’t recognize this obscure EKG change” rarely encourages people to do better – or be better.) So is solely focusing on the clinical side of EMS. You have to understand operations, law, policy, business, economics, human resources and all of the other “soft skills” that the pedantic EMS science types scoff at. Why does the fire department get what they want? PR and politics. And we don’t do that.

Yet another example from this same group of friends discussing EMS policy — a state is discussing prehospital administration of blood products. (Shameless plug — Texas has no state scope of practice or state protocols to limit such an initiative.) The state invited a wide variety of attendees. The room had only two paramedics attending but was full of nurse trauma coordinators. And when the inevitable policy rollout happens that doesn’t count for the realities of prehospital care, you can guarantee that every medic in that state will complain about how “EMS is controlled by nurses.”

I know some highly intelligent people in my EMS family. And many of y’all know OMI much better than me, the ALS hobbyist. But I also know who to call at the state EMS office and can get them to call me back. I also know how rulemaking works and how a county budget gets approved. For the long term success of EMS, I’d say that’s every bit as important as knowing that OMI is the new fancy term replacing STEMI.

You may not be interested in politics. But politics is interested in you. And when that happens, knowing pharmacology may not be as helpful as knowing how the city approves your department’s budget, how the state health department can change the scope of practice, or how the county awards the contract for a vendor to provide EMS services.

Enough with the British/Australian/Canadian Medic Comparisons.

First of all, apologies for not blogging in a while. Between practicing law during the day and two EMS roles that keep me busy, I tend to forget that I have a blog and only will wander over here when one of two things happen. One – when I get the email reminding me that I’ll be getting a bill for keeping the domain registration. Two – when something really inspires me. And right now, y’all are going to get both. And probably from both barrels.

This morning, I saw another one of those Twitter screenshots that goes viral around the EMS/emergency medicine/medical social media pages.

And said post upset and infuriated me. Not because of the truth or untruth of it, Rather, it’s trite and lacks understanding. So, as someone with quite a bit of education both in and outside of EMS and some experience with education and EMS policy, allow me to share my take.

Bluntly, I’m beyond tired of people comparing American EMS to EMS in any other country, particularly the United Kingdom, Australia, or Canada. All of these countries are dramatically different from the United States. Heck, compare EMS between different US states and you’ll see dramatic differences (Los Angeles County, California versus Texas – the land of delegated EMS practice.) Each of these countries have different forms of a national healthcare system and very different educational systems. (For example, an Australian bachelor’s degree is a three year degree as opposed to the typical four years here in the States.)

Bluntly, if American EMS is so awful, why does a large Louisiana-based private EMS concern keep getting Australian medics coming here? Could it be because maybe the grass isn’t necessarily greener in the Southern Hemisphere? The reality is that there’s a glut of degreed Australian medics and the jobs aren’t there.

If American EMS is so awful, where’s the peer reviewed studies comparing outcomes between American EMS and some of the countries with degreed medics? Most of the Med Twitter types that I see sharing these posts always want to “trust the science” and see the data. As of yet, I’ve not seen such data produced.

Oddly enough, American medics (well, excluding a few states that I won’t name like California) have a scope of practice that typically exceeds medics in these other countries. Securing an airway with paralytics, administering whole blood, and ventilators are common in progressive American EMS systems. In these other countries, they’re often reserved for graduate-level degree holding medics — or doctors. (Please note that, especially in the UK, flight crews are typically a medic and physician as opposed to our usual American model of a medic and a nurse.)

My blunt, candid take? A lot of these posts come from people who automatically assume that anything done outside of the borders of the United States is automatically better. Equally likely, these folks don’t understand the differences in EMS models, healthcare funding, and education that exist between the United States and these other countries. I’d also submit to you that many of these people haven’t had a great deal of exposure to EMS outside their own little corner of America — and assume that EMS is the same everywhere. It’s not

Can American EMS improve? Absolutely. Paramedicine shouldn’t be a jobs program for the fire union. Nor should it be delivered by the low bidder. And EMS providers of all levels shouldn’t be sitting in an ambulance for twelve hours a day driving all over town without an actual station to return to. Our education should not end at dropping the patient off in the emergency department. And we can fix much of this by beginning to educate the public about who we are and what we do.

That public outreach and education absolutely should NOT include selling American EMS short — and making us sound like the ignorant provincials that the Med Twitter illuminati think we are.

Recruitment and Retention: More of the Same

I was thinking about some of the recruitment issues that EMS is facing. Lots of large, well known departments are having challenges filling paramedic vacancies. Over the last decade, many of them have gone away from double medic staffing because of the shortage of paramedics.

Yet, we all know of EMS services, most of which are smaller and/or lesser well known, that are approaching full staffing. Funny thing is that many of these services aren’t even the best paid in their area or state.

I think we need to look at them and see what they’re doing. My guess is that it has a lot to do with culture and working environment. Those things tend to keep people around a lot more than a department appearing in the EMS media and/or having a “celebrity” EMS chief or medical director. The truth is, having supportive management, a station to return back to, and equipment that consistently works is going to make more of a difference in your EMS career than “working under Celebrity Medical Director” who’s regularly published and presents at all of the EMS conferences. And here’s where I’ll issue my semi regular reminder that the “Gathering of Eagles” (which some rightfully refer to as the Gathering of Egos) represents the medical directors of the fifty largest EMS systems in the country, NOT the fifty best EMS systems in the country.

And while we’re talking about that, more than a few of those EMS “celebrities” remind me of Paris Hilton – famous for being famous. An EMS organization that’s social media savvy or has an extensive PR program can have an outsized influence or reputation that may not match their actual reality, either operationally or clinically.

In that spirit, I share the following link from EMS1. The article should be titled “Water is Wet” as the statements are obvious and it’s basically the usual EMS commentary. People trying to solve the problems they created in the first place.

https://www.ems1.com/ems-advocacy/articles/the-ems-workforce-critical-condition-uQLsAE6niAsqzjvA/

If there is one thing that EMS excels at, it is our uncanny ability to believe that the people who created much of the current EMS mess, whether it’s education, operations, or clinical standards, can and should be trusted to sit on the next “blue ribbon panel” or “stakeholder group” to solve the problems they created in the first place. It’s little wonder that we still see EMS employers offering sign-on bonuses for so-called “high performance” EMS jobs which mean little more than a punishing call volume while you bounce around a city from parking lot to parking lot.

So long as EMS promotes the same celebrities who caused the problems they’re trying to solve, EMS will remain where it’s at. The solution? Look for the jobs at the departments that aren’t continuously hiring. Ask around. People who’ve been around for a few minutes in EMS know which jobs those are. Hiring bonuses, pizza parties, and self-promotion will only help a dysfunctional organization limp along so long. And until political leaders understand EMS and actually support EMS — with funding — these “celebrities” combined with the usual cabal of professional EMS committee members and stakeholders will continue to hold EMS back. And that extends absolutely to the current staffing crises we’re dealing with.

If you’re an EMS chief/director or a medical director and you’re wondering if this post is about you, it is well worth asking why people are leaving (or not applying). And actually addressing the problem rather than just boosting pay or giving incentives. People know the salary coming into a job. What they never know is what they have to put up with for the salary. Way too many EMS organizations ask people to put up with way too much for way too little salary. And that truth applies to volunteers too.

For Love of the Job

I have a few friends I consider extended family. One of them in particular feels like a brother from another mother. We have a similar taste for good food and sarcasm mixed with snark. And like me, he doesn’t do EMS full-time. He’s not paid either. He’s a pretty wicked smart (I think that’s the New England term) MBA who is in the financial sector full time and volunteers as a “paramedic light” and firefighter. He’s also acquired a taste for Texas BBQ. (You’re welcome for that trip to Cooper’s.)

He and I are in a group chat with several other like minded individuals. And yes, we’re probably talking about you.

But here’s what caught my eye this morning.

My friend mentioned the trust that the public places in us. The other night, he gets called for a six week old child with respiratory distress. In his own words, he says “it’s 99% likely panicking parent and 1% potential for ‘oh sh-t.'” Fortunately, the kid turns out to be ok. And I’ll quote his words on the next part, which is the key part. “Here’s the trust part: the other twin was crying so mom says ‘I have to get her’ and just hands me the little one. Has NO idea who these three guys standing in her living room are, never met or seen us before, we’re in a mix of regular clothes and ‘uniform,’ etc. Hands me the kiddo and goes upstairs like it’s nothing.” Exactly, my friend. Exactly.

He did a thorough assessment of the kiddo, then calmed the kiddo — and Mom and Dad. And whatever he was thinking about being woken up for what turned out to be a low acuity call, he made the patient and family feel as if they were all that mattered. (On that note, I’d note that there are more than a few paid EMS providers out there whose attitude is much less “professional” than my fellow volunteer in a small New England state.)

Years ago, a San Marcos cop told me that regardless of how silly it seems, to the person who called 911, it’s the most important thing that’s happened to them that day. It’s a lesson I try to remember when I’m responding and it’s the lesson I try to impart to those who I train and work with.

For those of us in emergency services and emergency medicine, we’re offered a ringside seat to humanity. Those who call us trust us implicitly. Let’s keep earning that trust. Train like it counts. Care for people like they’re your family. And never stop learning.

Earlier this week on Facebook, I said “Do the work. Be nice. Look like a professional. Polish your duty boots.” My friend from New England shared his experience that reminded me exactly why those things count — for both us and the public we’re trusted to care for. I hope I never violate that trust and that you don’t either.

What Does A Paramedic Need To Know?

When I was still a relatively new paramedic, I took an EMS instructor class. My instructor had also taught my paramedic course. While I’ve forgotten a lot about drafting lesson plans (which I think may be the educational version of nursing care plans — taught in school and rarely used in practice), I do remember him emphasizing the difference between “need to know” and “nice to know” when teaching.

Yesterday, while talking to an EMS friend, they mentioned that their service does a promotional exam to promote to paramedic. (Yeah, don’t get me started on the idea that paramedic is a promotion. The idea of not using someone’s education and skills to their full potential from the get-go is short sighted, especially while there’s a paramedic shortage.) They then mentioned the extremely low pass rate on this exam. Another thing I remember from my EMS instructor coursework and many other educational settings is that a low pass rate on an exam usually reflects a problem with the education, not with the students.

Then we discussed some of the exam, which included some subtle EKG minutiae about hyperkalemia criteria. That led me to thinking about how EMS education and exams love to focus on EKG details, especially 12 leads. And once I got to thinking about that, I decided to discuss this with some of my network of EMS friends, all of whom are smarter than me. The unanimous conclusion from them was that knowing specific EKG details for hyperkalemia probably wasn’t the best test of a paramedic’s knowledge. In fact, two of them (one an experienced paramedic who’s now an ED charge nurse and the other is a paramedic who’s now an advanced practice nurse) said their expectation was that a paramedic should recognize the peaked T waves on an EKG and report their findings as hyperkalemia should be diagnosed and treated based upon lab values. (By the way, I should mention that many paramedics, including me, have a very limited understanding of lab values in large part because our education doesn’t include that.)

This then led to several of us discussing what a paramedic should know — and what an assessment of said knowledge should look like. This led to a snarky, yet accurate comment from the advanced practice nurse. They said they’d be impressed by a paramedic who does three things.

  1. Take a good history.
  2. Bring patients to the appropriate hospital.
  3. Think beyond the next hour or two of treatment.

These seem to be skills that a paramedic should master and have down but seem to be regularly lacking.

I began to wonder why this is the case and my conclusion is simple. EMS education is heavily focused on solely the “emergency” aspect of healthcare. Most of our clinical rotations are in the emergency department of a hospital or on an ambulance. Needless to say, that makes a ton of sense. The challenge is that such an educational model and mindset leads to clinicians who have tunnel vision and little, if any, understanding of the rest of medicine. And that feeds right back into those three things that would impress the advanced practice nurse (and me, for that matter.)

The question is how to fix EMS education to give students more understanding of medicine and healthcare outside of the “emergency” setting. Not only would this understanding of medicine as a whole benefit our “emergency” patients, it would benefit our less acute patients who call EMS because we are their safety net and/or in their mind is having an emergency. As anyone who’s been in EMS for more than a few minutes recognizes, our patients’ definition of emergency doesn’t always match with our education and skill set of what constitutes an emergency.

First and foremost, every EMS initial education class from EMT on up should have a lesson on how EMS fits into the healthcare system. That lesson should be expanded, especially at the paramedic level, to discuss the different specialties of medicine and the roles of other healthcare practitioners. The lesson should also include discussion of hospital capabilities. And part of the field training and orientation process for an EMS provider MUST include a thorough orientation to the local hospitals that their EMS system transports to.

One other thing. EMS clinical rotations, especially at the paramedic level, need to include exposure to other parts of medicine. In an ideal world, I’d include a rotation with a hospital based internal medicine physician to provide a better understanding of chronic and acute illnesses as well as to provide at least an exposure to the types of medical cases that are routinely admitted. (By the way, there’s study after study showing that EMS clinicians routinely lack the ability to determine which patients who present to EMS are “sick enough” to be admitted to the hospital.)

Until we get EMS to embrace the medicine part of EMS as much as we embrace the emergency part of EMS, we’re going to remain the “ambulance drivers” without a place at the healthcare table. And no amount of discussion about EMS degrees, EMS 2.0, Med Twitter, or obsessing over EKG criteria will fix that.

FirstNet Fails

Anyone who knows me well knows that, outside of my passion for volunteer EMS, I also enjoy good food and sharing my opinions about good (and bad) food with reviews.  And more than a few of you know that the job that actually pays my bills is practicing law for state government where I routinely deal with government contracts and technology.

So, now that you know all of that, you might see why I feel qualified to give a review of FirstNet, the Federal government’s wireless communications initiative for public safety and public services that’s a public-private partnership with AT&T. My experiences aren’t isolated, as I’ve seen in multiple reviews on Yelp and Google as well as stories and complaints on Reddit and AT&T’s own discussion forums.

Generally speaking, the concept of FirstNet makes sense.  The idea of a wireless communications system designed to provide nationwide coverage for first responders and public service entities is an idea worth doing.  And a partnership between the Federal government and a national telecom company is imminently logical. The Federal government has the money and resources to partner with a national telecom company to provide the infrastructure for such a network.
I’ll say this much.  FirstNet is competitively priced.  The prices for its service are significantly lower than any other option.  And unlike most other wireless providers, FirstNet doesn’t throttle speeds and allows for unlimited tethering/hotspot use.  For someone who needs to complete reports in the field like I do at times, using my cell phone to provide a wi-fi signal to my tablet is a huge deal.

But those points are virtually the only advantages to FirstNet.  For one thing, their website for billing and subscriber services is, at best, clunky. For the first responder paying for their own phone on the network, the website is illogical and hard to navigate.  My best guess is that the web access was designed to be used by those managing multiple phones for an organization.

Let’s talk about FirstNet customer service for a moment. In short, it’s non-existent. The majority of customer service and sales comes from AT&T retail outlets.  Most of these stores are remarkably unaware of FirstNet and not every employee is capable of handling a FirstNet transaction.  When I first signed up for FirstNet, I had to call several AT&T retail locations before I could find someone to help me sign up.  And even at the location that promised someone to help me, I ended up being a training exercise while a new employee tried to navigate the FirstNet signup process.  I’ll return more to customer service as I expand on my biggest concern about FirstNet.

Even before 9/11, public safety recognized that interoperable communications and communications equipment were a weakness. FirstNet was and remains one of the Federal government’s cornerstone efforts to provide seamless, interoperable communications for emergency services. So, imagine my surprise when I’ve found that phones that are supposed to be FirstNet compatible aren’t. For radio communications, P25 digital systems are largely brand agnostic.  Motorola, Harris, EF Johnson, and others make P25 radios – all to the same standards. Yet, whether by oversight or intentionally, Android phones don’t seem to work on FirstNet unless you buy a phone from AT&T. When I first switched to Android, I bought a Samsung S20+ from Samsung.  The phone was unlocked and had FirstNet’s necessary Band 14 access.  Yet, I started to have problems with my phone not working on FirstNet. I went to the nearest AT&T store and was told that my unlocked phone that I bought from the manufacturer was not FirstNet compatible.  The AT&T store personnel switched me to a regular AT&T SIM card, but kept me as a FirstNet account.  In short, I was told I’d lose some of the network priority and preemption capabilities of FirstNet, but wouldn’t notice a difference.  That was fine until I switched to a Google Pixel 6 Pro that I bought directly from Google as an unlocked phone. Bluntly, the reason that I rarely buy phones from AT&T relate to the relative unavailability of phones at AT&T retail outlets, phones that usually have less storage capacity, and the significantly better financing and pricing offers from the phone manufacturers.

When I received my Google Pixel 6 Pro, I had some problems with getting the old SIM card in.  I went to the nearest AT&T store to get an e-SIM card activated. I was then told that NEITHER of my phones were FirstNet compatible and that they couldn’t activate either phone on FirstNet.  In fact, I was told that only AT&T phones had FirstNet capability because non AT&T phones rarely had Band 14 access. The “workaround” was to sign me up for a regular AT&T account with a first responder discount.  Not only is the plan slightly more expensive, it no longer has unlimited tethering/hotspot capabilities nor does it have the network priority/preemption capabilities.

As I had bought unlocked phones, I was quite confused and concerned that neither of my IMEI numbers showed to be FirstNet compatible.  I decided to contact the FirstNet Authority, which is the Federal oversight and planning agency for the implementation and management of the FirstNet program.  I sent an email to the FirstNet Authority and began to speak with the regional representative for Texas, who definitely understood and appreciated my concerns. He assured me that I did NOT have to purchase equipment from AT&T and told me of several agencies that purchased their wireless devices from other sources and had no issues with FirstNet compatibility.  He proposed getting me in touch with AT&T’s regional FirstNet representative for the Austin area.  The AT&T regional representative had a lot of explanations at first, including that many unlocked phones aren’t meant for the US market and that AT&T couldn’t guarantee their compatibility because of missing Band 14 coverage. I then informed the AT&T representative that both my Samsung and Google phones had been purchased from the manufacturer. The AT&T representative first said that I needed to change out my new phone for the AT&T specific model number and to contact Google for that. When I reached out to Google, their technical staff told me that the phone was unlocked for all carriers and that it had an unlocked bootlogger.  I was also directed to the technical specs for the Pixel 6 Pro which showed that all models have FirstNet Band 14 capabilities.  I then recontacted the AT&T representative who said that merely having Band 14 capabilities did not mean that the phone was guaranteed to be FirstNet compatible and that my model had not been certified.  Since sending the AT&T representative the technical specs from Google, AT&T went silent for a while, then I heard from them claiming that the IMEI number is invalid.  They continue to tell me that I may need to return the phone to Google to buy a FirstNet ready phone.  And presumably, that means an AT&T purchase since an unlocked phone purchased directly from the manufacturer somehow won’t work on FirstMet.  Again, I’m pointing out that FirstNet appears to be creating a situation where AT&T is the de facto sole source of FirstNet compatible devices, at least for Android. 

Considering this, I have emailed senior leadership at the FirstNet Authority as well as the National Telecommunications and Information Administration at the Department of Commerce, which oversees the FirstNet Authority.  Again without a response.

Now, here comes my government contracts attorney side.  One of the things I’ve learned with public-private partnerships is that the private entity rightfully wants to recoup their investment. Sometimes, though, that means that the private vendor will take steps to ensure that only their product can be used.  I’ve seen that before with state contracts for services such as fingerprinting services for applicants for state licenses. What’s odd about the case with FirstNet is that AT&T seems to be implicitly requiring the use of AT&T phones (at least in the Android world) to use FirstNet. Yet, the FirstNet Authority believes that the FirstNet platform is supposed to be an open platform for compatible devices. I’m unsure exactly what has happened, but it’s clear that AT&T has been given the keys to FirstNet and the FirstNet Authority is failing to oversee the contract. Whether AT&T’s actions are intentional or accidental, the FirstNet Authority exists, in large part, to ensure that the private vendor is operating within the bounds of their agreement with the government, even more so as a recipient of public funds.

In short, FirstNet is definitely failing to live up to the expectations of being an interoperable wireless communications network for emergency services and public service.  The failings of the FirstNet Authority to oversee the actions of their contractor, AT&T, have created a situation where AT&T has been given the gift of a Federally approved monopoly to sell wireless devices to our nations first responders.

Without action from the FirstNet Authority, I believe that the next logical steps are an investigation by the Department of Commerce’s Office of the Inspector General, the Government Accounting Office, and/or Congressional inquiries.

As for my “Yelp review” of FirstNet, it’s a one star. The price is excellent, but clearly AT&T has given the first responder community this pricing at the trade-off of being bound to AT&T for devices, which are often more expensive and less capable than readily available unlocked devices sold by the manufacturer.  While I am not an antitrust lawyer, this tactic, both in terms of consumer sales and government contracting, bears investigation for potential antitrust or consumer protection claims.

EMS Week Thoughts

Over the last week, which happened to be EMS Week, I tried to do a Facebook post each day with my thoughts on EMS for EMS Week. Here’s that collection for y’all…

Sunday, May 16

Happy EMS Week to my EMS friends and extended family.To those of my friends who aren’t in EMS, now’s your chance to ask questions. And please, understand that EMS, EMT, and Paramedic are not interchangeable terms. EMS is Emergency Medical Services — the organizations made up of people who provide prehospital medical care. EMTs are emergency medical technicians. And paramedics represent the highest level of education and skillset in prehospital care.

Monday, May 17

I’m going to try, with no guarantees (see, there’s my lawyer side showing) to do an EMS related post every day of this EMS Week. And since a lot of people are posting about their early days in EMS, I’ll shamelessly follow that trend. In 1999, as a bored second year law student at Texas Tech, I signed up to do a ride along with Lubbock EMS because the Lubbock Police didn’t allow rides. Needless to say, after just over sixteen hours with Jackie Buck on 9744 running a cardiac arrest and a really weird car wreck, I was hooked. I pretty much became a regular around Lubbock EMS and I realize how annoying I was as someone without any training. During my return trips home and prior to getting my EMT, I also had quite a few Austin/Travis County EMS crews putting up with me. (Thanks Warren Hassinger for always answering those emails…)In 2004, I got my EMT certification and started doing things for real at CE-Bar Fire Department/Travis County ESD 10. In 2006, I decided EMT wasn’t enough and by 2007, I got my Texas licensed paramedic patch…It’s been a heck of a ride and I wouldn’t give up the experiences, education, and most importantly, the friendships, for anything. I truly have the best of both worlds practicing both law and prehospital medicine.

Tuesday, May 18

Another #EMSWeek post. I’ve been a bit of an EMS nomad over the years, having volunteered up and down the I-35 corridor of Texas as well as the Houston/Gulf Coast area and the Texas Hill Country. I have the fortunate luxury of being able to walk away from EMS because of my primary career. But if you want to know how/why I’ve been a bit of a nomad, it’s simple. I know what I’m getting paid as an EMS volunteer. Namely nothing. Zilch. Nada. Zero. What I don’t know is what I’ll have to put up with at an EMS agency. In other words, how much do I have to put up with before I decide to move on?Most in EMS don’t have that ability. But we continually lose the best and brightest to other fields, especially nursing. Maybe it’s time to look at the culture of EMS, including how we treat our fellow medics and how we develop and promote leaders. Because, let’s face it, there’s easier ways to make $15/hour than to be micromanaged while moving from parking lot to parking lot for 12+ hours at a time. If we want EMS to remain a viable career (or even become a viable career), we’ve got to treat each other better, especially our employees. Otherwise, we will never improve because we will be in a constant cycle of hiring and replacing people who’ve left the profession for something else. In some cases, people leave EMS for ANYTHING else.This EMS Week, we must do better.

Wednesday, May 19

fancy themselves influencers. More than a few of them have taken positions on social and political issues. That’s fine, although my politics usually trend differently. More than a few pride themselves on not being prejudiced. Good for them.But one form of prejudice and bigotry exists on a lot of EMS pages and groups — and seems to be tolerated, if not outright promoted. Namely, bias against one group of EMS providers — volunteers. It’s the one place where the IAFF and the “social media influencers” of EBM and third service EMS meet.These people talk about morons as volunteers, talk about how volunteers take jobs from EMS, and how there’s “not volunteers running the library, picking up the trash, or fixing the streets.” Having experienced some of the mismanagement and shenanigans in volunteer fire and EMS, including the mindset that a volunteer status is an excuse for lowered standards, I empathize.But when I remind them that I’m a volunteer, I get the answer of “you’re different.” It reminds me of the excuse “some of my friends are of XYZ group” when you call out other forms of bigotry.Is there incompetence in volunteer EMS? Absolutely. I think we all know examples — and have seen it promoted. (See also: New Jersey First Aid Council.)However, volunteer emergency services, whether EMS or fire, can — and do — work. In many of these communities served by volunteers, the only alternative would be to have a large commercial EMS operation from a nearby area pick up the community and respond from even farther away, potentially leaving the area with even more substandard coverage.Volunteer EMS has its pros and cons — just like any other model of EMS system. It can work. It does work in some areas. It’s also an abject failure in other areas, especially when the cliques and personalities override patient care and responsibilities to the community.Having said that, bias against volunteer EMS service seems to remain the last acceptable prejudice in EMS circles, particularly on social media.

Thursday, May 20

And as threatened, here’s today’s #EMSWeek post. Two words that EMS routinely fails to grasp are promotion and education. In two cases, these terms are inextricably linked.1) We absolutely stink at public education and promoting who we are and what we do. We’ve largely succeeded in educating the public to “call 911 for an emergency.” Yet, we’ve never told the public what’s an “emergency.” Anyone who’s spent time in a 911 ambulance knows that our definition of emergency and the public’s definition don’t match up. Also, we haven’t told the public much about us or what our capabilities are. See also: members of the public using the terms ambulance driver, EMS, EMT, and paramedic interchangably. See also: questions like “why is there a fire truck when I called for an ambulance” or “what do you mean there’s a bill.” To get the raving fans in the public that other public services like the fire department, parks, and libraries have, we have got to create a generation of educated, raving fans who will advocate for EMS.2) Also speaking of promotion and education, we don’t educate or even prepare the people we promote. “Fred is a good medic. Let’s make him a training officer” is soon followed by “Fred is a good training officer. Let’s make him a supervisor.” None of this is accompanied with any leadership education. And when you don’t develop leaders, at best, you develop managers. Managers look at metrics and take direction, then pass it down the chain. In other words, there are a lot of EMS managers and damned few leaders. Think about that when you’re working for an EMS provider whose business model requires you to drive around town and park in 7-11 parking lots for 12 hour stretches. The abject lack of leaders who advocate for EMS and for their team are exactly why EMS is how it is, where it is, and why the current paradigm stinks. And to add fuel to the fire, there’s more than a few of the current (and previous) generation of EMS grand poobahs who continue to dominate the EMS committees, work groups, etc. They’re hanging on to their fading relevance and routinely tell new faces to “wait their turn.” Once again, EMS has met its enemy — and it’s often us.

Friday, May 21

Another #EMSWeek thought to ponder. It’s good, heck it’s imperative, to be current on one’s medicine. And it’s right that EMS education focuses on the application of science to medicine.But that’s just one part of being informed, educated, and successful in EMS. One also needs to understand the world of EMS operations — because what makes EMS different from most of the rest of the world of healthcare is where and how we deliver medical care — namely outside of clinical settings.And perhaps most importantly, we need to understand the business, economics, law, policy, and politics of EMS. Because if we don’t own those spaces — someone else will. And invariably, those people don’t necessarily have EMS’s best interests at heart. (See also: virtually every state or Federal EMS committee where the EMS practitioners are outnumbered by the other “stakeholders.”)

Saturday, May 22

Final #EMSWeek post. I’ll leave you with two thoughts. First, it’s a privilege to do this work. Strangers trust us to enter their lives at their worst moments and trust us to know and do what’s right for them. Second, EMS can be fun. For me, it’s a huge change of pace from the practice of law and the constant meetings, emails, and issues that drag on for a long time. As long as you keep those two things in mind — and have a life away from EMS as well, it puts everything else about EMS into perspective. And if you’re not having fun with this, ask yourself if it’s you or if it’s where you’re at.