Medicine and Politics

I get it.  Social media, outside of a few select areas, takes a fairly liberal bias.  And there’s more than a few folks who believe that being liberal is consistent with being educated.  I get that.  As a lawyer, I’m one hundred percent committed to upholding your constitutional rights to free speech, assembly, and petitioning the government.  That’s guaranteed by our Constitution, which is a pretty unique document and guarantee of your rights and liberties as an American citizen.

Here’s where I dissent.  There’s a lot of hashtag activism going on in the medical world on social media.  There’s a ton of people who’ve taken some very strong positions because they disagree with the current President of the United States.  That is well and good.  Again, it is your constitutional right.  I have two objections to this mindset.  First, there’s a bit of a violation of trust with the consumers of these clinicians’ social media feeds.  When your social media presence is that of a “Free and Open Access to Medicine” (aka FOAM) advocate, I rarely expect to see politics.  I expect to see medicine.  As both an attorney and a medical professional, I get that one may hold strong views and perhaps even consider them as part of your professional identity. I don’t expect to see a veiled insinuation (or in some cases, outright statement) that opposing the position of the United States government is part of one’s ethical obligation as a clinician. Further, I don’t expect to see the continued belief that being “educated” means you take a certain political worldview.  Perhaps we should recall and recollect about the collective clucking of tongues at physicians and pharmacists who refused to be involve with the “morning after” pill.

By all means, if you’re asked to do something unethical, stand up.  Stand up for your beliefs as well.  But using your megaphone to shout your beliefs in the ears of those who you’ve brought to your social media home to hear about medicine is, in this guy’s opinion, a violation of that trust. And that goes doubly so when the dissent doesn’t even involve the practice of medicine.

Gresham’s Law and EMS Social Media

In economics, there’s a concept called Gresham’s Law.  Gresham’s Law states that bad money drives out good.

Sadly, the same is often true in EMS social media.  Bad discussion, particularly in some forums, drives away good discussion.  Most EMS pages on Facebook in particular are dominated by the loudest voices in the forum – most often poorly educated providers who repeat dogma, dated information, and flat out incorrect information. Combine that with some who want everyone to be “supportive” and not discourage people and you have a forum where bad information drives out good information.  Many of my intelligent colleagues in EMS and medicine have tired of trying to educate the unwilling.

And then, there’s another factor at play as well.  People in many of these forums want to discuss unlikely or arcane scenarios to the detriment of mastering the basics of good medical care.  Random medical-legal scenarios involving revocation of care, bizarre EKG cases, and random trauma pictures flood EMS social media.  Yet, there’s still a significant chunk of EMS providers who think that you can reverse a cardiac arrest with dextrose or naloxone (Hint: You can’t.) or that a long spine board is mandatory for every patient (Hint: The National Association of EMS Physicians and all of the current science says no.) And let’s not even talk about the number of providers at all levels who think that all respiratory difficulty gets treated with a nebulizer full of albuterol.

Bad information from bad participants drives out good information from the people who might know something. There are too many EMS social media participants who are constantly analyzing zebras when they can’t recognize the herd of horses coming towards them.

I don’t have a solution.  As the old saying goes, you can lead a horse to water, but you can’t make them drink.  While I try to educate when and where I can, I find I’d rather work with those who want to learn and want to improve themselves and their practice of medicine.  When you find those people, it makes it all worthwhile.  Until then, don’t forget the over the counter pain medicine of your choice from banging your head against your desk.

Be scared. Be very scared.

I saw a post in an EMS forum from a newly minted EMT expressing fear and trepidation about their knowledge base and their readiness to perform in the field. After some reflection and even a dose of cynicism and sarcasm, I hereby put these thoughts out there for the entry level EMT.

EMT is among the easiest certifications to get with the lowest barrier to entry and relatively low standards. Less than 200 hours of training should scare you. It’s but an entry level certification and a remarkably simple achievement. Holding yourself out as any sort of medical professional or hero with this little training should scare the heck out of you, your colleagues, and your patients.  And contrary to the t-shirts, very few paramedics are “saved” by EMTs.

But in all fairness, I don’t blame you.  I blame the EMS profession and some EMS educators and recruiters who’ve promised you that your entry level education will save lives and make you a hero.  If you haven’t already figured it out, much of what you were trained for rarely happens.  Some of those neat bandaging and splinting tricks (many of which are straight out of the old Boy Scout and Red Cross first aid texts) will never enter into your career.   The things you glossed over, namely medical emergencies and patient assessment, are the bread and butter of EMS.  You’re in a service career that deals with people.  And the general public doesn’t follow the same definition of emergency that you got in your class.  Remember, these are the folks that called their doctor after hours and got a recording saying, “If you’re having a medical emergency, hang up and dial 911.”  Thus, enter EMS — and the call nature that you don’t consider an emergency. In short, the reality is that you’re much more likely to use your ability to talk to a patient than you ever will an occlusive dressing or a traction splint.

So, what to do?  Well, first of all, as they say in the movie Jarhead, “Embrace the suck.”  In other words, embrace the fact that your new field involves much less heroism and much more service and caregiving.  You’ll be less disappointed and less burnt out along the way.  Second, recognize that a certification of minimal entry level competence is the entry to the field, not the pinnacle of achievement.  In other words, the real learning starts now.  Whether it’s podcasts, social media, journals (NOT trade magazines), or conferences, you need access to real medical education.  Finally, have a life outside of EMS.  Have hobbies, have a family.  Don’t wrap yourself solely in the identity of being an EMT (or a paramedic. Or even an attorney.)  And with that advice, you’re closer to ready to embark on your path in EMS, regardless of your certification.

Saving lives? Occasionally.  Providing service?  Every day.

We Aren’t Nurses. And Nurses Aren’t EMS Providers.

For the record, I’m sick and tired of the nurse bashing. Not here, but on EMS groups in general. While there’s some overlap between EMS and nursing, the two are entirely different fields and both have a special place. Sometimes, though, EMS proves its special place involves a crash helmet and a short bus.
EMS has very specific education (some might call it training) in a very specific field.  We are the experts in providing autonomous, independent immediate care, usually in non-clinical settings.  We excel at providing immediate care to acute patients in the first hour or so of care.  Honestly, in these settings, EMS does represent definitive care.  What makes EMS unique is our ability to deliver this care outside of a hospital/office setting.  I like to describe us as medical providers using a public safety background to deliver patient care. Talk to more than one experienced nurse or physician about EMS during a cardiac arrest and you’ll hear them acknowledge our very specific expertise in providing care during those first crucial moments of an acute medical crisis.  Outside of the immediate care setting, we start to flounder.  It’s not our fault.  It’s just that’s not what we’re educated to do.
Nurses.  Nurses are different.  Their education is much broader and focused on a wide spectrum of settings.  That makes nurses excellent generalists with opportunities for specialization. While it’s true that most nurses (and possibly even some ER nurses) border on helpless in an emergency setting, I can equally guarantee that most EMS providers would flounder at best in a setting where you’re caring for a patient for more than an hour, day after day, and probably more than one or two patients at a time (except in the most acute care settings in a hospital). And unlike EMS, nursing licensure is easily transferrable between states and there’s a ton of career opportunities in the practice of nursing, nursing administration/management, and nursing education.  Not to mention graduate degrees that provide real value in terms of careers.
EMS providers have knowledge of medicine that’s a mile deep in one field (emergency medicine).  Nurses have a knowledge of medicine that’s a mile wide.  Yes, there’s some overlap between nursing and EMS, as there is with any of the medical professions.  Just because I have skills with an endotracheal tube and a bag-valve mask doesn’t mean that I’m the same as a respiratory therapist. Nursing and EMS are complementary fields.  Neither is a springboard to the other.  Having said that, some of the best clinicians I’ve seen are those who are both RNs and paramedics.  They truly bring the best of both worlds to their patients.  And yes, EMS providers’ skill sets and knowledge belong in settings other than ambulances.  Paramedics would be great additions to the hospital and clinical settings as more facilities recognize the value of paramedic assessment and intervention in the rapidly deteriorating patient.
Let’s quit trying to compare ourselves to nurses.  Let’s quit trying to define ourselves by what we can do.  Instead of bashing nurses, maybe we need to ask why what EMS has been doing hasn’t worked for increasing our pay and respect. The short answer?  The public doesn’t know who we are or what we do.  Combine that with low entry standards and equally low educational standards and we’ve become the Rodney Dangerfield’s of medicine — No respect, I tell ya.

Yes, We Are A Service

We keep seeing the pleas and exhortations to “pay EMS workers what they deserve.”  I get it.  We’re underpaid.  Or so we keep hearing.

Whether we are employed by a public or private entity, we’re still a business.  We get paid for our services, whether through tax money, patients’ payments, or reimbursement through private or public insurance. That means that we’re selling what we do — and if we don’t have customers, we don’t have ambulances — or paychecks.

The number one goal of any business is to have (and keep) customers.  (Of course, there is an exception to every rule and in the USA, the businesses that don’t understand customer retention are cable companies and cell phone providers!)  And the truth be told, we in EMS do a terrible job of gaining and keeping customers.

Let’s talk about gaining customers.  The fire service and law enforcement get it.  They routinely engage in public relations, outreach, and public education. These organizations go out of their way to make themselves visible and engage the community in almost way they can.  If a citizen shows up at a fire station, you can almost guarantee they’ll be offered a tour, a cup of coffee, and a warm greeting.  Show up at an EMS station and what happens?  Probably a grunt, at best.  Fire Prevention Week?  The firefighters are making the rounds.  National Night Out?  The cops will be there.  And probably the firefighters too.  Social media?  Most PDs and FDs have Facebook pages where they share and brand their message?  EMS?  Not so much. We have EMS Week?  What do we do?  Well, for one thing, we complain about whatever “freebies” the hospitals give us.  Maybe we’ll put a crew somewhere and give the same blood pressure checks you can get any day in the waiting areas for most pharmacies.  Ride-alongs?  Sure, some organizations allow them.  Many don’t, claiming HIPAA, liability, or some other red herring. Showing off the ambulance?  Explaining EMS training?  Nope, most places don’t do that either.  Wonder why people confuse EMTs and paramedics or just call us ambulance drivers? Wonder why people call us for non-acute reasons and then drive themselves to the ER when it’s a “real” emergency?  The reason is simple ignorance.  Ignorance can be cured.  But we’re too content to complain as opposed to educate. Most PDs and many FDs have a “citizens’ academy” program where they provide the public an insight into their world.  With the exception of MedStar in Fort Worth, I’ve yet to see an EMS program do this.  But again, we complain at the lack of respect given to us.

The lack of respect given to us.  Yep, we complain about that all the time.  But do we show any respect to our customers?  Yep.  Customers.  And if we have customers, we have to have customer service.  I could spend hours on customer service.  But I won’t, because I can distill it into two key takeaways.  First, be nice.  Second is “why be nice?”  The simple reason is that nice providers are less likely to be complained on and even sued.  The reality is that the overwhelming majority of our patients don’t know anything about the quality of our care.  What they do know about is how nice we are to them.  Please, thank you, sir, and ma’am go a long way — as does a genuine attitude of caring.

Of course, I’m probably preaching to the choir here, but maybe we need a “card course” for customer service.  In conclusion, we all complain (INCLUDING ME) about how fast food workers don’t deserve $15/hour because they don’t get our orders right.  Maybe we don’t deserve $15/hour yet either — because we don’t educate people as to our worth nor do we treat people like customers.

The next time you deal with the public, remind yourself one thing.  They’re a customer.  And without customers, there is no EMS.

To The EMS Students And New Providers

Let’s be honest.  EMS culture at some times can be toxic. We have a ton of stations where gossip, a “good old boys” club, a “mean girls” club, or hazing occupy the down time and set a horrendous tone.  In too many EMS organizations, the precepting and field training processes become a bad parody of some sort of boot camp environment where breaking down a new student or provider, hazing, belittling then, or teaching them merely to practice medicine exactly as their training officer is the sad norm of things.  I get it.  We’ve got a culture problem in EMS and we can all improve.

Many of our new students and providers are coming out of college-based programs.  (One result of the accreditation process, whether intentional or unintentional, beneficial or harmful, is that college-based programs are more likely to have the infrastructure and resources to navigate and succeed in the accreditation progress.)  There’s been a lot of discussion about the current “snowflake” or “cupcake” culture and how many students want validation.  While my experience is merely anecdotal, one of the words that I see students and new providers abuse is the word “supportive.”

I routinely see/hear/observe people using the word supportive to mean that they only seek validation.  They use the word to stifle any criticism and to discourage dissent.  The reality is that, maudlin posts and attention seeking memes aside, the practice of medicine (and that does include EMS) is serious business.  We’ve been given a position of trust, responsibility, and even some authority. That means there are right and wrong answers in what we do. There are very real consequences to much of what we do.

In short, it’s each of our responsibilities to be supportive.  But it’s also our obligation to ensure that supportive doesn’t become a way to validate and enable poor providers. Supportive should never mean a lack of accountability. Each of us do have a responsibility to “enable” our students and new colleagues — and that should be to enable to become the best clinician possible.  Nothing else is acceptable.

Charity Begins At Home

Recently, I’ve seen more than a few EMS types posting requests for crowdfunding for them to engage in medical work, either as a medical missionary or in solidarity with various protest movements.  I get it.  The urge to help others, especially in moments of extreme need, is a huge motivator for many of us in public safety or medicine. (And yes, that’s controversial right there.  EMS is a mix of public safety and medicine.  We use a public safety model to deliver medical care.  Prehospital care is what I like to call “operational medicine.”)

But, to me, asking for crowdfunding to subsidize your passion reeks of so much that I don’t like about EMS.  There’s a vocal portion of people in EMS who are all about “LOOK AT ME!  VALIDATE MY EXISTENCE!  I’M DOING SOMETHING NOBLE AND YOU SHOULD APPRECIATE ME!”  It’s so common throughout EMS, as we see with the t-shirt and bumper sticker brigade. I get it.  We want to help.  But it seems that, for a vocal portion of EMS providers, we only want to help when we’re getting attention. (Bonus points if you appeal to social justice and get subsidized for being a medical activist…)

Bluntly, if you’re having to get others to pay for your altruism, you probably aren’t in a financial situation to be taking the time off to travel to a faraway land, whether overseas or even in the USA. It’s, at best, highly irresponsible.

The honest-to-God (or insert your deity of choice) truth is that there’s plenty of places local to each of us without access to medical care.  Heck, there’s plenty of places within an hour’s distance of each of us that are probably lacking access to quality EMS care and would love to have a passionate, dedicated volunteer provider on board.

Way too many folks in EMS make fun of volunteers and claim that volunteers are responsible for poor EMS standards and low wages.  Yet way too many people in EMS volunteer — when it gets them attention and a partially funded trip out of town.

As the old saying goes, charity begins at home.  Find your local service or local medical organization where you can begin to address the lack of care locally.  Ok, rant over.

A Note Of Optimism

I’ve been away from the blog a bit, mainly as a result of some writer’s block.  With an upcoming trip to the Texas EMS Conference to speak (Tuesday, November 22 at 2:00 PM, by the way) and to get some continuing education, I’m more rejuvenated about EMS than usual.  And then, tonight, I heard from a dear friend of mine who works for a large, urban third-service EMS system in Texas.

She proceeded to tell me about her patient earlier this evening (without violating patient confidentiality), while working a high-volume truck in the inner city.  Her patient needed to go to the hospital for treatment of an illness that had been lingering for a long time.  She made arrangements to have all of the patients’ belongings moved as that was one of his objections to getting care.  She then administered pain medicine because “that looked like it <expletive> hurt.”

Honestly, it’s what we’re supposed to do.  But a lot of us miss the mark.  But ultimately, she took care of a patient, got them to care, addressed their pain, and gave them a bit of dignity.  Stories like this don’t make the news.  They don’t make great t-shirt slogans.  But taking care of the least among us is exactly what EMS is supposed to be all about.  Things like this remind me why it’s a privilege to be a medic and why it’s truly a sacred honor to take care of patients.

I’m not a Bible verse kind of guy, but her patient care tonight reminds me of this verse, “whatever you did for one of the least of these brothers and sisters of mine, you did for me.”  And ultimately, that’s the standard we should strive for as medics, as public servants, as caregivers, and as human beings.

Enthusiasm

There’s a lot of enthusiasm on EMS social media and some of the most enthusiastic of these people want you to know just how much enthusiasm for EMS.  There’s a lot of people saying how much they love being in EMS.  There’s a lot of those people sharing pictures of ambulances, fire trucks, helicopters, and badges. These are usually the people who have all the cool sayings, catchphrases, and memes down.  These are the ones about heroism, pride, sacrifice, and everything else all-American and apple pie. There’s also a group of marketing types who make a fair amount of money selling T-shirts to those enthusiastic EMS types.

Here’s what I never see from those types.  I rarely see why they’re enthusiastic about EMS.   And I never see their enthusiasm about the MS of EMS — medical service.  These people are never at the EMS conferences, except at the vendor’s booths getting their latest “Big Johnson EMS” t-shirt. If they go to continuing education, it’s because it’s mandated.  They share the hero stuff.  They don’t share the medical stuff.  And what they do share about medicine falls into two typical categories — war stories and dogma. For them, it’s even better if they can share both. “There I was, taking this guy to the ER who’d slipped and fell.  Good thing we put him in a C-collar and a backboard because he had a hairline fracture of C-3.  You can’t ever be too careful.”  These are the same people who believe that cutting edge medicine involves a backboard, a non-rebreather mask, and a diesel bolus.

I’m enthusiastic about EMS.  What I love is that it’s an opportunity to help someone and provide medical care when someone doesn’t know where else to turn. And to me, that opportunity to serve comes with an obligation to provide the best care possible. There’s an imperative to be up on the medicine.

EMS social media is a phenomenal tool for networking with like-minded providers and to share the latest developments in medicine.  I am incredibly thankful to some great, smart EMS professionals online who’ve shared their tricks of the trade with me. I’ve learned more about Ketamine, sepsis, rapid sequence intubation, push dose pressors, and countless other topics from the online EMS world than a hundred local classes could ever have attempted to provide. And when I’ve despaired over things, whether in EMS in general or in my personal EMS world, there’s been a friend out there who’s shared the same frustrations.  But social media friendships, just like “real world” friendships, are highly dependent on who you choose to associate with. As the old saying goes, “choose wisely.”

In conclusion, it’s great to be proud and enthusiastic to be in EMS.  The challenge is to channel that enthusiasm into being a provider that provides a service to your patients. If not, you’re just another whacker.  Don’t be that whacker.

A Media Time-Out

I’ve gotten tired of the media.  I’ve gotten tired of the same stories appealing to the uneducated masses.  I’ve gotten tired of the same talking heads spreading the same talking points.  You thought I was talking about the upcoming national election in November?

Wrong.  I’ve gotten tired of the EMS media, both print and online. Virtually every EMS social media, online presence, and print publication consists of the same things. A few clinical “advances” highlighted, usually by a professional EMS Celebrity, the right EMS system, and/or the same cabal of professional committee members who’ve created the mess that is modern EMS — but wait, this time, they’re really going to fix it.  Then, there’s all the stuff to tell you what a hero you are.  Yes, you should wear your lack of education, your immaturity, and your inability to feed a family on an EMT paycheck as a badge of honor. And the majority of EMS “news” sites consist of results of content searches.  If a news article mentions “EMS” or other keywords, it gets shared on EMS news sites.  In my mind, this partially explains the Narcan for everyone craze — because, golly gee, they keep reporting on heroin and other scary drugs.

And EMS social media is more of the same.  Pandering to the least educated of the profession mixed in with some hero worship and mindless adulation because merely going to a job that involves less than 200 hours of initial education makes you a hero.  And by God, if you can’t pass an exam that measures minimal entry level competence to safely function, then don’t worry.  We’ll keep encouraging you and tell you to keep chasing those dreams, no matter how unrealistic they are, you special snowflake!

At times, you’ll see EMS media get it right.  The cover of the current edition EMS World is about prehospital ultrasound. Some of my friends in EMS who want to advance EMS as a profession and expand the role of EMS providers have tried, with occasional success, to raise the bar.  Yet, the reality is that there’s always more average and below average EMS providers to consume the media.  And in a capitalist society, we go where the money is.

I don’t know that we can fix the problem.  What I do know is that there is plenty of good educational material out there to be an informed, current provider.  You just have to look for it.  There’s even some good stuff online.  If you’re not familiar with FOAM, you should be.  There’s some incredible cutting edge medicine being spread on social media.  I like the quote that Dr. Joe Lex says:

If you want to know how we practiced medicine 5 years ago, read a textbook.
If you want to know how we practiced medicine 2 years ago, read a journal.
If you want to know how we practice medicine now, go to a (good) conference.
If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM.

 

And that brings me to the final point that I have regarding becoming and remaining an informed practitioner of prehospital medicine.  If what we are doing is medicine — and I believe it is, then we need to be getting our education from physicians. I admit to being a nerd about medicine. I have several physician level texts that I use to expand, broaden, and challenge my notions about medicine.  And a personal goal is to attend more physician level professional education.

A rising tide may not always lift the rest of EMS, but I believe that if the smartest and most motivated of us in EMS demand more for our professional development, just maybe, we can start to be taken seriously as professionals.