EMS Week Thoughts

Posted on May 23, 2021 Written by

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.

Filed Under: Uncategorized

EMS – Starting From Scratch

Posted on February 25, 2021 Written by

Right now, there’s some controversy in Texas EMS circles over a pilot program to combine EMT and paramedic education into a single program where an entry level student wouldn’t need to be an EMT before entering paramedic education. I am cautiously optimistic for this concept, but I’m also sure it will need tweaking along the way. EMS is the only career field I’m aware of, at least in healthcare, where you have to obtain a lower level certification in order to advance. Registered nurses don’t have to become vocational/practical nurses first. And physicians don’t start out as physician assistants.

In this spirit, I started to wonder what other sacred cows I’d slay. With my squirrel brain, that quickly morphed into how I, your humble scribe, would completely redesign EMS from scratch.

First, get rid of the Emergency Medical Responder certification — or what Texas calls Emergency Care Attendant. EMT becomes the new certification for first responders, whether police officers, firefighters, or other personnel. On that note, aside from politics and inertia, why do we have the fire department doing first response prior to EMS arrival? Why not have law enforcement or even community based organizations doing EMS first response?

AEMT would become the minimum staffing level for a 911 ambulance. Of course, there can and should be a process for rural communities to make the case for EMT level staffing due to unavailability of AEMT and/or paramedic staffing.

Non-emergent transfers would be done by nursing aides and/or vocational/practical nurses with training in operating a van and patient movement. Non-emergent transfers should not be part of the EMS world. EMS resources should be dedicated to 911/emergency calls and critical care transfers only. On that related note, medical facilities, especially skilled nursing facilities, should be required to use the 911 EMS system for emergency calls. These facilities should also be financially sanctioned for using the 911 EMS system when a transfer company is not able to respond to a non-emergent transfer.

To supplement the 911 AEMT/Paramedic crews, advanced practice paramedics with enhanced education and skill sets in critical care and community paramedicine riding in SUVs to supplement and assist on 911 calls. These paramedic clinicians should function as true physician extenders to help patients navigate the healthcare system, engage in alternatives to transport, and considering alternate destinations besides the hospital emergency department. A paramedic clinician with telemedicine capabilities and point of care lab testing could present a huge opportunity for cost savings throughout the healthcare system.

In my ideal EMS world, there would be 3 ways to become a paramedic. Much as some nursing programs have a bridge course for vocational/practical nurses to become registered nurses, EMS needs a paramedic transition curriculum for those who are already AEMTs. Also like nursing has alternative entry BSN programs for those with a bachelor’s degree, we need a route for a paramedic certificate as an add-on for those who already have a bachelor’s degree. In this revised EMS world, most people would get a bachelor’s in EMS that covers the current knowledge base as well as the things we don’t cover, but need to advance in EMS — courses in management, policy, economics of healthcare, and adult education methods. The ideal EMS degree should be preparing graduates not only as paramedics, but as the future managers and leaders of our profession.

The current proposal of creating the associate’s degree as the entry level EMS degree accomplishes little beyond awarding college hours for what is currently, by and large, a technical degree in the career/technical education side of the community college world. EMS is a medical field with more in common with nursing, respiratory therapy, and dare I even say, medicine than it has in common with career/technical education like diesel mechanics or heating and air conditioning repair.

Everyone wants to fix EMS, especially those of us in EMS. All but the most naïve realize that any solution is going to require funding. Funding is a challenge whether the service is directly funded by the government or whether EMS is a private entity. There’s one untapped source of EMS money that most of us aren’t considering. As the more astute in EMS know, the Center for Medicare/Medicaid Services (CMS) only reimburses EMS for transports, not treatment. Until EMS speaks with a united voice and focuses our Federal legislative efforts on this change as opposed to quixotic, feel good legislative initiatives, we are doomed to poor pay, poor equipment, and a seat at the kids’ table of the Thanksgiving dinner that is the American healthcare system.

Am I wrong on this? Maybe. But unlike a lot of the others purporting to speak for EMS, I’m not unwilling to challenge the status quo. Johnny and Roy are but a memory to the newer generation in EMS and it’s time that we stop considering the original model of EMS responding to cardiac events and collisions as what constitutes an EMS system, much less a functional, successful EMS system.

Filed Under: Uncategorized

The Right EMS Degree

Posted on December 21, 2020 Written by

Because I haven’t thrown out any EMS dynamite in a while, here we go…


I oppose the idea of a mandated associates degree for paramedics. Much of what it will do is to guarantee a monopoly to community college programs. These programs are often judged by completion, not success on the licensing exam. Additionally, these programs are often unavailable in rural communities. Many of the community college programs have shown an unwillingness to provide distance education and/or adjusted schedules for students unable to do a full-time day program.


My solution? Make paramedic a post-bachelor’s certificate. By doing so, you’ve already guaranteed that you will have students who’ve demonstrated an ability to think critically, complete a course of study, and to communicate. In other words, much of the affective domain has already been evaluated and validated. I’d also surmise such a paradigm shift will have lower attrition and have graduates, who by the very nature of their education, have the familiarity with standardized testing to succeed at the National Registry as opposed to viewing it as a mysterious hurdle that represents the pinnacle of professional accomplishment. Whereas, the reality is that the National Registry represents the minimal competence to safely function as an entry level provider.

We’ve all said it’s easy to teach the skills of a paramedic, but it’s much harder to teach someone to think critically and relate to patients. By requiring a college degree before becoming a paramedic, we’ve already found people who know how to think and (hopefully) relate to others.


And before you say that paramedicine doesn’t pay well for someone with a bachelor’s degree, I’d encourage you to look at the salaries for teaching and social work, both of which require a bachelor’s at a minimum. The truth is that EMS can and does pay a decent salary to the motivated individuals who seek employment with the more professional EMS systems as opposed to the employers who operate on a “patch and a pulse” mentality. Eventually, bachelors’ level paramedics will require two things that many EMS systems are unwilling or unable to provide — namely a decent salary and a less toxic work environment.

This won’t (and can’t) happen overnight. I’d argue that we need to look at making this the requirement in the next ten to fifteen years. And to remove one obstacle, let’s agree from the outset to grandfather in everyone who’s licensed as a paramedic before that.

Further, let’s do two more controversial things at the same time. First, we need to demand that paramedic is the ONLY advanced provider in the field. No more “cardiac techs,” “Intermediate-99s,” or the like. Next, like any other real healthcare field, we should not require completion of a lower certification to enter a paramedic program. Paramedicine is a separate profession from the technician level providers and it’s time we recognize this.

In short, paramedicine needs to be a professional education, not a technical education — even if said technical education leads to a terminal level associate of applied arts/sciences with limited mobility into a bachelor’s degree.

If we don’t dream big, EMS professionals are destined to remain viewed as ambulance drivers by those in healthcare, business, and government who act surprised when you tell them there’s a difference between an EMT and a paramedic.

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The Lawyer Says Enough

Posted on October 12, 2020 Written by

Many of you who know me, whether in person or via social media, know that I complain about people expecting free legal advice. Between you, me, and the fencepost, I’ve actually done quite a bit over the years for the EMS world, whether it’s for personal friends, EMS organizations, EMS publications, or EMS conferences.

This morning, I received a Facebook message from a college EMS faculty member with a very specific legal question that was clearly about an ongoing issue for their institution. When I told them that I did not have an immediate answer and would require research, they began to pout and ask where they could find the answer.

Here’s some reality. First, legal questions don’t always have a simple yes/no answer. As such, they require legal research. Second, legal questions, even seemingly innocent ones, can raise ethical issues. Notably, these issues can be made even more treacherous when you (typically your organization) is already represented by counsel. As I’ve noted in previous blog entries, asking for legal advice has the potential to create an attorney-client relationship. When such a relationship is created, it also creates obligations and responsibilities on me as an attorney that go well above and beyond answering a simple question.

I find it ironic that there are a lot in the EMS world, especially online, who state that volunteer EMS prevents EMS from receiving the compensation it deserves. There may be some validity to this argument, but said argument loses much of its support when EMS folks expect free legal advice. As I stated to today’s offender privately, this is the equivalent of me asking a paramedic to provide me with free transport or treatment — or asking an EMS instructor to provide me with an ACLS class for free. In other words, knowing how to research and how to synthesize the law is how I make my living to pay for my EMS hobby. (Slight sarcasm and exaggeration goes without saying there.)

I’ve heard from several of these types how they’re only asking me as a fellow EMS provider. I call BS on this. Most of these folks know more than a few EMS providers, often who have significantly more EMS experience that I do — whether as an EMS field provider, educator, or manager. What said other “peers” don’t have is a professional degree and license to give legal advice. They’re looking for “a lawyer told me XYZ is the answer.” As I’ve said earlier, that answer carries certain ethical as well as legal ramifications for me — and those aren’t things I’m likely to undertake for free for a Facebook friend I hadn’t talked to in years.

Over the years, I’ve considered some of what I do in the EMS legal realm a form of paying back to the EMS community that has given so much to me. I’ve made a ton of friends over the years, gained a ton of confidence, and occasionally used the knowledge to help others. But the sense of entitlement from others has gone too far.

I’ve given freely of my time and expertise at my own sacrifice for too long. I’ve always been willing to support our EMS community and advance the profession. But freely answering legal questions is not something I can do.

And since this isn’t the first time I’ve mentioned this — and how it causes ethical issues for me as a legal professional — I’m less likely to be as nice as I have been in the past. To the last person who asked for advice, congrats. You’ve given me the courage and impetus to start saying “no” to much of the EMS world.

If you want legal advice, understand you’re asking an attorney for it. Said professional expertise comes at a price. And that price includes a retainer agreement and payment for said expertise.

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Where EMS and education collide

Posted on October 10, 2020 Written by

This morning, I read an article with great interest about our local EMS system using a physician assistant who’s also a paramedic to provide enhanced EMS care — both for acute patients and to divert non-acute patients from the emergency room. The truth is that such a program has a ton of merit and would probably benefit a lot of EMS systems. While the funding may not be there, I personally believe that controlling the loss of funds from unreimbursed ambulance transports might be worth the money alone.

But this article illustrates a bigger problem with EMS. Namely, that a paramedic certification leads nowhere, except maybe a paramedic to RN bridge. The truth is that we know a lot of things about emergency medicine — and if you’re a decent provider, a lot of that knowledge carries over into other aspects of medicine. But there’s no recognized mechanism to transfer that knowledge to another discipline. And even if it did transfer over, most people in EMS don’t have the pre-requisites to get into other programs. Me included as my BA was a very studied attempt in avoiding hard science courses at UT because those courses were used to weed out pre-med students.

And the funny thing is that a MD friend of mine said she never uses those courses in her work. The truth is that the health care education field requires the wrong prerequisites. They attract people who do well in science and not necessarily those with the ability to communicate or even those who want to be caregivers. We see the results regularly, especially with physicians, when we see a clinician who can describe lab values to the molecular level but can’t communicate with a patient or their family, let alone show empathy.

We need to address two things as EMS. First, we need to find ways to bring our skillset, clinical knowledge, and life experience into healthcare above and beyond the usual two options of being on the ambulance or being a “tech” in an emergency department. Second, we need to encourage those in health care academia to recognize that alternate pathways to higher education in medical care can and should be recognized. I’d much rather attract clinicians with a proven interest in medical care as well as exposure to medicine than I would people who’ve checked off the right arbitrary coursework and who’ve never seen a sick person, much less talked to one or their family.

The challenge is for us to convince everyone else that an EMS certification brings something to the table when we want to move past working on the ambulance or the emergency department.

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EMS Education — Some Easy Places To Start

Posted on July 10, 2020 Written by

Right now, EMS is being asked to step up its game and take on more of a role in healthcare.  Even before we knew about COVID-19, EMS was being asked to do more in terms of reducing repeat patients and finding alternatives to the “you call, we haul” mentality that’s been the mantra of the American EMS system.  Of course, that’s in large part due to much of EMS reimbursement being based upon Medicare and Medicaid reimbursement models, which often get adopted by private insurance as well. And since CMS pays for transport, not treatment, EMS is going to focus on taking patients to the hospital.  And in large part, the EMS education framework focuses on immediate life-threatening conditions and the treatment thereof both in the field and in the hospital emergency department.

However, we’ve reached a point where it might be valuable to reexamine our educational framework — and maybe even make a few changes that might improve our long term prospects for EMS.  Because of COVID-19, we’ve got two new challenges.  First, we’re being asked to do more in the prehospital arena.  In many locales, paramedics and some EMTs are now able to refer or transport patients to alternative destinations.  While this change was already starting to occur, COVID-19 accelerated this.  It’s now almost semi-routine for EMS providers to tell non-acute patients that a quick ride to the emergency department is no longer the solution, whether because of the load on the EMS system or emergency department saturation. In fact, the Center for Medicare/Medicaid Services (CMS) had already rolled out a pilot program for select EMS organizations to “treat and release”prior to COVID-19.  And during the current pandemic, CMS is authorizing payment for transport to alternative destinations and some “treat and release” scenarios. And second, because of the pandemic, many of the traditional EMS clinical rotations have become unavailable for EMS students.

Rather than seeing these challenges as threats, maybe it’s time for EMS educators to reevaluate how we’re educating our future EMS providers and what we’re teaching. Anecdotally, my EMS experience has been that a lot of EMS providers have occasions where they end up transporting patients to hospitals unable to provide definitive care for the patient.  Sometimes, that’s a result of protocols or local politics. However, many EMS providers often have a remarkable lack of knowledge about medical care and capabilities outside of emergency care. This leads to two pitfalls.  One, EMS providers take the wrong patients to the wrong hospitals. Two, EMS providers have little knowledge to fall back upon beside “transport to the emergency department.”

It’s time to make two simple changes to EMS education.  First, let’s add some education, even a few hours, on the rest of the healthcare system running the gamut from acute to sub-acute, from inpatient to outpatient, from primary care to specialty care.  And let’s talk about what the different healthcare professionals and medical specialties do.  Giving us a bigger picture of where and how we fit into the world of healthcare and medicine can’t harm us.  And for those that say the EMS curriculum is already full and “there’s no room to add any more,” let’s take a look at what we’re currently teaching.  I’m pretty sure we can sacrifice some dated or low frequency topics like the Kendrick Extrication Device, seated spinal immobilization, or petroleum gauze.  Next, while clinical sites are limited, let’s look at getting EMS students into alternative clinical settings.  I’ve long believed that a rotation in urgent care, especially a pediatric urgent care facility, might provide students as much, if not more, skills and observational opportunities than many current rotations — and might have a better connection to reality.  Also, I’d suggest that EMS students might benefit from time in physician’s offices, especially specialist physicians.  The opportunity to interact with physicians AND see how chronically ill patients are managed outside the hospital would give EMS providers much needed perspective. On the same note, I’d like to see EMS students given the opportunity to follow physicians on the hospital floors.  Seeing patients only in the EMS and emergency department setting doesn’t always give perspective to the continuity of patient care. And finally, seeing as how EMS often has to deal with the failures of our healthcare system, especially for elder care, EMS students need to be exposed both to skilled nursing facilities and also to hospital discharge planning.

Addressing the education if EMS while we’re currently dealing with COVID-19 and the current financial and educational climate will put EMS in a position to both improve patient care and expand the scope of EMS for the future.

 

 

Filed Under: EMS, EMS Education

A Solution to EMS Stagnation?

Posted on June 23, 2020 Written by

As I look at EMS’s stagnation in comparison to nursing, I have a thought. Nursing has made it where a Registered Nurse is the minimum level of entry to almost any acute care role — and where an associate’s degree is the minimum education level at best.

If we’re going to push the EMS degree narrative, we need to ensure that paramedics become the de facto provider of acute prehospital care. The Emergency Medical Technician should become the Certified Nurse’s Aide of prehospital medicine — in other words, not associated with acute care — except in a first responder role.  As a friend and colleague of mine noted, an EMT’s skill set makes an immediate difference in a few cases — rapid defibrillation, tourniquet application, and the use of an Epi-Pen.   Interestingly enough, those are all skills taught in the American Heart Association’s First Aid curriculum, once again providing credence to my belief that EMT education merely adds on to a general course in first aid.  While we’re at it, in my ideal world, EMT and paramedic education would be separate, albeit with a track to advance from EMT to paramedic.  You don’t have to progress from CNA to LVN to RN, although there are programs for LVNs to transition to RN.  We should do the exact same for paramedics.

Combine that with defining the role of a paramedic (which I see as rapid assessment, stabilization, and initial treatment) in statute and zealously protecting that role from intrusions by any other profession and you might actually get EMS to become more like nursing.  In my view, nursing has succeeded for three reasons.  First, nursing defines what it is.  Second, nursing makes sure that no one else intrudes on their defined role.  And finally, nursing is willing to engage in the political process to protect their role.

Let’s not do what Canada does and call every EMS provider a paramedic.  Let’s reserve the paramedic title for those who actually do what a paramedic does.  We don’t lump physician assistants and physicians together.  Let’s keep paramedic OUR title.  Of course, that also requires us, as paramedics, to educate the public and our government about what we do — which seems to be the one thing that we are still either unable or unwilling to.  See also:  the general public, other healthcare professionals, and government officials mixing the terms ambulance driver, EMT, paramedic, and first responder.

In summary, we need to define what a paramedic is, protect said role, and ask the public to demand paramedics.  As the advertising slogan goes, “Accept no substitutes.”

Filed Under: EMS, EMS 2.0

COVID 19, Free Money, and Excuses

Posted on April 20, 2020 Written by

This is a bit far afield from my usual blogging about the world of EMS, but if you think big picture above and beyond considering what clinical skills an EMT or paramedic should have, maybe this is exactly about EMS.
A couple of things about COVID-19 and business and government. As most of y’all know, I’m a practicing attorney with over 16 years of experience in government law, so I think I have some qualifications to comment.
 
1) In regards to the availability of the various loans, contracts, and grants, especially to small businesses and individuals that all levels of government are providing, it’s no surprise to me that they’re not getting where they need to be. Government moves slowly, even when it’s trying to move fast. And when it does move fast, it often fails to consider how the program will work. (See the current Paycheck Protection Program loans and how they seem to really overlook certain businesses, especially the restaurant business.) There’s an art to doing business with or getting money from the government and it usually takes a level of sophistication to navigate it. Sometimes, it’s not merit that gets the money as much as it’s the person or company that knows how to fill in the paperwork best. Early in my career in state government, the state agency that I worked for regularly contracted for advertising services for a public relations campaign. The company that regularly got the contract had hired one of our agency’s former office managers.  One of said manager’s duties prior to leaving state employment was reviewing contracts and preparing the bid and contract documents.  In other words, that company knew exactly which forms to fill out and what answers were expected on the document. And how does this relate to EMS?  Simple. Let’s think about some of the EMS grants out there.  We know that certain EMS agencies nationwide have the expertise to apply for grant funding.  These same agencies get every grant they apply for  Meanwhile, there are small EMS services struggling to keep supplies on the ambulance that have neither the time nor the savvy to navigate the grant process while at the same time, the right large systems get a WMD trailer, a HazMat truck, and a tactical medicine supply that would keep the Green Berets and SEALS stocked for the next ten years.  Or there’s a Federal grant program available only to certain types of recipients.  For example, a grant for EMS may only be available to local government entities or to fire-based departments and will completely overlook private non-profit departments.  Moral of the story?  It often takes a lawyer or at least someone savvy with the ways of government to tap into the “free government money” that the media reports on.  And just as surely as the media will report on two things after this pandemic goes away.  First, they’ll report on some entity that did or didn’t get the money and why that’s a travesty.  Next, when the pandemic stockpiles get recreated and funded, there will be a story within the next two years about “exposing government waste” and a “warehouse full of supplies that no one has ever used.”
2) Failures.  The truth is that COVID-19 is causing unprecedented failures, whether in business or healthcare. And those failures need to be documented and measured so that we don’t make the same mistakes in the next pandemic or disaster.  BUT… it’s also a convenient excuse for failure too. There are stories of deaths being attributed to COVID-19.  At least here in the Lone Star State, death certificates allow for the listing of contributing factors.  So, while COVID-19 might have killed someone, their underlying conditions may have contributed. Or maybe the underlying conditions killed the patient, but the COVID-19 contributed.  COVID-19 might be the cause of death or it might contribute.  This applies outside of medicine too. Lately, I’ve been reading about restaurants “closing due to COVID-19.”  Yes, COVID-19 was probably the final straw.  But if you had a business already in decline, maybe COVID-19 was only the contributing factor.  Or you could have self-inflicted factors caused by your own business decisions. See also the restaurant that refused to allow delivery services BEFORE the pandemic and then closed one of their locations, even for to-go orders, at the first quarantine action by local government. Business, especially the restaurant business, is a Darwinian process with low profit margins.  Relevance to EMS?  I’d also note that EMS is known for low financial margins and is heavily reliant on government funds, as is much of healthcare.  Throwing any disruption into this narrow financial margin and there’s bound to be a financial catastrophe. (See also: nursing homes) In short, it’s always easier to blame an outside event than your own failings and decisions. Case in point being a long time local restaurant deciding to close “due to COVID-19” at the same time that the owner planned to close in the next few months due to retirement and rising rents.
3) And I’ve saved the most controversial post for last.  Let’s talk about quarantines, “stay home, stay safe,” or the popular phrase “flatten the curve.” I am the absolute first to say that COVID-19 isn’t the flu.  It’s a literal pandemic.  And we know that, right now, there’s neither a cure nor a vaccine. As such, we have to take drastic actions to slow the spread of the disease, save lives, and equally importantly, save the foundations of our healthcare system. And to get people to take drastic action, we have to create a sense of urgency. As such, we’ve told people to stay home.  We’ve closed schools and offices and told people to work from home if they can.  We’ve made the decision to take a massive hit to the economy to spare lives and lessen the strain on our healthcare system.  That decision is a no-brainer.  It’s the right decision and it remains so, especially without either a cure or vaccine for this disease. But the models predicting catastrophe have changed and reduced their estimates.  Granted, some places in the United States, like the New York City corridor, have born a terrible price.  (Population density is a real curse in pandemics.) At this point, if ever, we’re unlikely to know if the decrease in deaths is due to our social distancing efforts, better treatment regimens, or a flawed modeling scheme. At some point, whether now or at a still to be determined time, we will have to reopen the country and our economy.  The cure for the pandemic may be the death of our economy.  Clearly, we’re going to have to address this — and smarter minds than my own will have to weigh in.  I am pleased that our political leadership is looking for advice from those outside of the medical field.  While the medicine is crucial in this discussion, my own experience is that the medical community, probably more than any other field I’ve been exposed to, tends to believe its knowledge of healthcare trumps all other concerns and their expertise on health requires immediate deference on all other fields. Regardless, I’ve noticed that our society has changed over the four decades that I’ve been around.  Whether its societal evolution, the 24 hour news cycle, or a climate where social media gives everyone, even the unqualified, the same ability to spread their opinion, we’ve changed. The biggest change I’ve noticed is that our modern society is afraid. We’ve grown to demand safety over all else and find any risk intolerable.  Risk must be mitigated to an infinitesimally small factor. In other words, Karen from Nextdoor has become the avatar of our society.
Sorry for the rambling and the massive diversion from the usual EMS discussions.  Or wait…. maybe this discussion of government, failures, and risk versus safety is EXACTLY what EMS needs to advance.  As I’ve harped more than once, the practice of medicine (including EMS) involves much more than scientific knowledge and clinical skills. Medicine is like engineering or architecture — it applies sciences to human problems.  As such, medicine has to factor in more than the hard sciences.
Thanks for listening.

Filed Under: Law, Politics

Early Lessons/Thoughts From COVID-19 for EMS.

Posted on April 12, 2020 Written by

Because the science is evolving on COVID-19, we know that the end lessons from this may be different.  But I’d like to throw of my early observations out early for consideration.

First and foremost, all of the EMS grants, training, and attention paid to tactical EMS, mass shootings, explosives, and weapons of mass destruction, the real test and draining of EMS has come from an unrelenting call volume brought on by a novel, pandemic respiratory virus.  None of the MOLLE gear and self-absorbed incident command classes are worth much in this.  Except for one aspect of incident command — namely logistics.

Second, we’ve once again learned that EMS has little surge capability. I’ve discussed this before. And most EMS (and fire) services that have transitioned from being rural/suburban combination organizations to small paid departments claim they can rely on mutual aid.  That’s well and good until EVERY system is facing the same demands. Then, you’re waiting for the state and federally contracted providers to deploy within the week.  Maintaining a part-time and/or volunteer program helps relieve some of the stress on the system.

Next, if there’s one key lesson to be learned from this pandemic, it’s that EMS needs better personal protective equipment (PPE) and infection control practices above and beyond parroting the buzzword “BSI.”

In that light, I’d hope that after this, every EMS system makes appropriate PPE available. And that needs to include changes of uniform. (I’ve lost count of how many EMS services think that the part time guy only needs one uniform shirt and nothing else.)

My recommendation for after this is to have an adequate supply of surgical and N95 masks on each rig along with appropriate cleaning supplies. Everyone should get at least 2 complete changes of uniform. Ideally, there should be a couple of pairs of scrubs on board the ambulance/response vehicle in the event you have to decontaminate before returning to the station.

I’d surmise that many of the logistics problems EMS faces stem from two things.  Number one, we stink at public outreach and education.  Most people don’t even think about EMS.  Second. we’re not sure if we’re healthcare or public safety.  That makes it harder for us to access those things reserved specifically for healthcare — or traditionally provided to healthcare organizations.  It took advocacy from the American Ambulance Association to make Amazon’s healthcare specific “store” open to EMS organizations. And at least anecdotally, the public health bureaucracy which administers the majority of the pandemic response often forgets about the needs of EMS. In fact, I’m not unfamiliar with disaster response from both my career in state government as well as my EMS work — and I’m still not sure what, if anything, EMS is getting from the Strategic National Stockpile.

What would I like to see happen?  I’d like to see proper preparation for the next time, because there will be one.  And I’d like to see adequate supplies of both equipment and personnel.  But being an attorney with experience in government, I’m a realist.  And considering this experience. I am cynical enough to have a good guess of what will happen. There will be a massive initial push to get all of this done. There may even be Federal grant money to make this happen. 99.9% of the Federal grant money will be awarded to departments that don’t really need the money. 99.9% of said awarded equipment will dry rot and expire in a warehouse. Some TV newscast will run a story on “a storeroom full of stuff that no one uses” and the stuff will be surplused. Then when COVID-2023 makes its debut, we’ll be right back at square one.

The other thing my cynicism has convinced me of is that the majority of the funds made available for the next pandemic will go to the various public health bureaucracies, certain hospital networks, and the politically connected fire services.  Why?  Because those are the people with the political savvy to navigate the legislative, bureaucratic, and grant processes.

Filed Under: EMS, Politics, Rants

EBM. Do you know what it really means?

Posted on April 8, 2020 Written by

Right now, in this time of COVID-19, there’s a lot of unknowns. There are known unknowns and unknown unknowns, to borrow a phrase from Donald Rumsfeld. Right now, many of those unknowns, both known and unknown, apply to the treatment and management of the disease.  Less than two weeks ago, very educated and skilled clinicians were treating COVID-19 patients like Acute Respiratory Distress Syndrome (ARDS) and intubating patients early and placing them on a ventilator — often with terrible results for the patient  as well as overwhelming the critical care system. As we have increased our understanding of the disease, we’re finding it’s less a ventilation issue and much more an oxygenation issue with a breakdown of iron in the bloodstream.  We’ve gone from intubating patients to laying patients prone with high flow oxygen — not to mention seeing better results.

And like with any emerging issue in medicine, especially when there’s a dearth of known treatments, physicians will try novel treatments, including the off-label use of medications already in use. One of those is hydroxychloroquine, sometimes administered in conjunction with azithromycin. There have been some reports of success of treating COVID-19 patients with this combination, enough so that the President has become a loud cheerleader for this combination.  Whether you adulate, like, dislike, or loathe the current President, no one can deny that he’s a master showman who understands the power of the bully pulpit that being the occupant of the Oval Office gives you.

And because the treatment is being advocated by one of America’s most polarizing politicians, there’s immediate opposition to the combination of hydroxychloroquine and azithromycin.  If you’ve been around any EMS (or even any medical) discussions on social media, especially Twitter, politics routinely injects itself into medicine. There are a lot of physicians and clinicians of all types who feel a joint obligation to both medicine and being “woke.”

Right now, the woke clinicians on social media are opposing this particular treatment regimen in the name of “evidence based medicine,” believing that the double-blind study is the only acceptable evidence of the efficacy of a treatment or medication.  (I’d note that many of these people who poke fun at religion have a similarly blind faith in “science.”)

Yes, the double-blind study is the sine qua non of scientific evidence. I’d like a double-blind study to confirm everything that I do in medicine. But that can be taken to an extreme.  See also the satirical double-blind study of parachutes.

For everyone who blindly opposes new medical interventions based on their own scientific education obtained from the Twitter Institute of Advanced Studies and sharing Neal DeGrasse Tyson memes that repeat the phrase “science,” I’d submit that you don’t know where and how the phrase “evidence based medicine”comes from.  While evidence based medicine, also known as EBM, arose in the medical field for use by clinicians, it rapidly became the watchword of the managed care industry.  In 1985, Blue Cross/Blue Shield began using EBM to evaluate new treatment regimens. In 1991, Kaiser Permanente began using EBM guidelines for treatments.  In other words, the previously science-oriented concept of EBM became a cost control mechanism by implemented by managed care.

In other words, the people pushing the EBM mantra lack the understanding of what EBM is and how it differs from the scientific method.  In science, we should absolutely be pushing for the scientific method.  In an ideal world, we’d have the time, resources, and ability to do randomized double-blind studies on everything we do in medicine.  But we don’t.  And when humans are suffering, maybe sometimes we need to consider ethics in conjunction with a blind devotion to EBM or the scientific method.

Of course, the study of ethics is rarely absolute. It’s full of nuance and variations. And as I’ve discussed before, that’s something that neither EMS nor much of social media excel at. It’s almost like those “core courses” in humanities and social sciences might be a bit more relevant than the Twitter Science Brigade believes.  Neither medicine nor science should have an agenda.  But precisely because social media and the 24 hour news cycle exist, the very term “science” has taken on a political bent.  (e.g. “Science is real.”)

On a final note, while medicine is based in science, I consider medicine an applied science, much like engineering.  Medicine isn’t a pure science.  Rather, it’s the application of science and knowledge to practical problems.  It’s time that we all remember that — and that an education involves much more than science alone.  And science is more than sharing links from Twitter. Science is but one part of a well-rounded education, something which most of the medical world seems to have forgotten.

And that devotion to absolutism in the name of EBM or science is but another symptom of the divided red versus blue world that we’re currently in. Sadly, even a disease like COVID-19 has done little more than highlight the deep divisions in our country.

Thanks for reading.  And we will get through this — just as we got through the Great Depression, World War II, and 9/11.  On that note, “Let’s roll.”

Filed Under: EMS, EMS Education, Rants
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