The Semi-Regular Reminder on EMS Politics

Yep. It’s that time again. “EMS On The Hill Day” is just around the corner.  As we all know from EMS social media and the EMS “Powers That Be,” AKA:the usual conference speakers and the people who now provide consulting services to fix the messes that they created in the first place, merely showing up one day in Washington DC in a uniform that’s a cross between Idi Amin and the Knights of Columbus will magically fix all that is wrong with EMS.

 

I’ve worked in state government for years.  I’ve been a lawyer for years.  I’ve been involved in many political campaigns and involved in political parties.  I’m telling you — that’s not how any of this works.

 

We can fix EMS through the political process.  But it’s going to take more than one day per year in Washington DC.  Here’s what it’s going to take.

  1. MONEY.  Money fuels politics.  The reality is that politicians need money to get elected.  Money buys access to the game.  In other words, you can’t watch the game if you don’t have a ticket.
  2. All politics is local.  This famous quote from Tip O’Neill is so true. The Federal government has a limited role in the provision of EMS services, much of which relates to the role that Medicare/Medicaid funding plays. Local governments make the decisions on how to provide (and fund) the EMS system.  State governments typically are the ones who license and regulate EMS personnel and services.  And here we continue to think that the solution to EMS lies in Washington DC. State EMS associations need to step up the advocacy game.  Period.
  3. This is a year round sport.  EMS has to be engaged in the advocacy process year round.  Even in states like mine where the Legislature only meets every two years, there’s plenty going on in the “off season,” which is when interim studies happen and future legislation gets planned.
  4. It’s all about the staff.  Elected officials’ staff members are the subject matter experts and they help the officials develop their positions.  Their schedules are usually much more open than the elected official — get to know them and turn them into your ally.  In turn, they may well call upon you for input — and influence.
  5. The regulatory process matters. Getting legislation passed is great.  But oftentimes, the devil is in the proverbial details.  That’s why it’s imperative to be involved in the rulemaking process and in monitoring how the various regulatory agencies implement and interpret the law.
  6. Funding matters.  When you get funding, things happen.  If you want to fix EMS, fix the laws and regulations that reimburse EMS for being a transportation service rather than a medical service.
  7. Present the image of being professionals.  You want the elected official or their staff to consider you a professional they’d trust, not someone who looks and acts like they just got out of a clown car.

 

Of course, we all want the quick and easy answer to “fix” EMS.  We’ve been trying the quick and easy answers for years and here’s where we are.  Maybe it’s time we try what the adults have done to get their various professions a seat at the table in terms of funding and professional recognition from government.

Your Ride-Share To The Hospital

There have been several articles lately about the use of ride-sharing services like Uber and Lyft to get patients to the ER.  In one article, AMR is looking at a yet-to-be-defined partnership with a ride-sharing service.  Another article making its way around the EMS social media circles describes people getting a ride to the hospital from one of these services.

Of course, the schizophrenic nature of EMS raises its ugly head.  You’ve got some people saying, “About time.  These people don’t need an ambulance because they’re not having an emergency.”  And then you’ve got other people taking the other extreme position in EMS, namely, “If we don’t take you to the emergency room in an ambulance, you could become ‘unconscious, comatose, or dead,'” — just like the speech that most EMS providers give when obtaining a refusal.

Why should we be offended or bothered by this? EMS social media is constantly filled with complaints about how people should only use the ambulance for “real emergencies.” Now that people do, I notice some of the comments are about the risks of not going by ambulance. So, what’s it gonna be?
EMS can’t have it’s cake and eat it too. Do we want people to use us? Or do we want to discourage using EMS unless it’s a real emergency? And of course, how is the lay public to know what’s a so-called real emergency?

And as I’ve said more than once, we somewhat have ourselves to blame for everyone calling 911 for a ride to the emergency room.  Especially in comparison to the police and fire services, we’ve done a terrible job of public outreach and education.  Everyone knows who the cops and firefighters are and what they do.  Us?  Not so much.  It’s amazing how many people don’t even know that there’s a difference between an EMT and a paramedic and what they do. We’ve delivered one message well, perhaps.  That message is “If you’re having a medical emergency, call 911.”  When you combine that simplistic message with the failure of American/Western medicine to deliver medical care outside of a 8:00 AM – 5:00 PM, weekdays only model and end up sending patients to multiple specialists, labs, and imaging centers all on those same inconvenient schedules, is it any wonder that John Q. Public decides to “call 911 for an emergency.”  In other words, EMS and emergency medicine have become victims of our own success.  People know that if they need medical care, EMS and the emergency department exist and won’t turn anyone away.

What we really need are trained professionals who have the ability to assess and transport/refer to someplace in addition to the ER. And while we’re verbally masturbating over whether to be offended by this or an Arby’s ad, we’re not doing what we truly need to be doing — developing our profession into the role of a mid-level provider who’s able to deliver both the medicine and the patient in a manner that meets patient needs in the most cost effective way possible. And what emergency medicine needs to do is to actually read EMTALA, provide a “screening exam,” and refer non-acute patients to an alternative setting.  However, we need these prehospital mid-level providers and these alternative settings to exist in the first place.  I recognize there’s no funding stream as of yet, which is one of the major failings of the so-called community paramedicine initiative.  The truth is that you sometimes have to spend a little to save a lot.  That’s a truth that our government and healthcare payment systems have yet to grasp.

McDonald’s Applied To EMS

Nope, this post has zilch to do with EMS wages, so put those pitchforks away. Rather, I’ll ask a semi-rhetorical question.  Why do people stop at McDonald’s when they’re travelling?  It’s simple.  People know what they’re going to get and they like consistency. A McDonald’s in Boise isn’t going to differ all that much from a McDonald’s in Miami. By doing such, tourists may miss out on an incredible local diner. Just as likely, though, they could miss out on food poisoning by visiting a so-called local institution.

As of late, it seems that EMS is taking the McDonald’s approach to medicine where consistency is valued above all else. Again, as is the case with dining options, an obsession with consistency drives away exceptionally low standards and performance.  But it also seems to drive away high performance as well. And unlike a Big Mac, prehospital medicine in rural Nevada with long response times and limited access to hospitals is going to need to differ from a compact, urban center like Boston with multiple academic medical centers.

A good friend of mine has asserted that there’s a growing advocacy movement for mediocrity in EMS.  I’m not sure I’m ready to go that far.  But I do believe that the movement in EMS that pushes buzzwords is hurting EMS.

The buzzword movement pushes catchphrases such as metrics, data, standards, accreditation, “best practices,” and regularly misuses “evidence based medicine” in an effort to ensure a level of uniformity, consistency, and mediocrity in prehospital medicine.

The buzzword movement obsesses maniacally over cardiac arrest survival rates because dead/not dead is an easy metric.  Nevermind that cardiac arrest represents a very small part of what EMS does and that most out of hospital cardiac arrests are not salvageable, it’s an easy metric, so it becomes what determines “success” in EMS. Symptom relief and routing the right patients to the right care are nowhere near as easy to quantify, so these things (which EMS should be getting right) get overlooked regularly.

I’d much prefer that EMS systems focus less on consistency and compliance and more on excellence. From my experience in prehospital medicine, I’ve found that if you encourage medics (of all levels) to achieve a high level, most medics will do their best to reach it.  As the old axiom goes, a rising tide lifts all boats.

Instead of striving for consistency, I think it’s time for EMS to strive for excellence.  Even if we occasionally miss said mark, we’re going to improve rather than stagnate. Our patients deserve a commitment to excellence, not a commitment to consistency — which all too often has become shorthand for mediocrity.

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.

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.

Thinking About EMS Education

A friend, grizzled EMS veteran, and sage (all the same person) recently opined about the state of EMS and it got me to thinking. So, allow me to share my thoughts on initial EMS education and perhaps offend everyone in EMS and EMS education all at once.

I’m not sure that accreditation or degree requirements improve EMS one iota. What they do is create artificial barriers to non-college-based programs. There are plenty of good programs that aren’t affiliated with a college. And there are colleges that turn out crap EMS providers. Speaking purely anecdotally, the colleges know this.  The local college in my area offers the paramedic program only as a full-time, daytime only program.  There’s no alternative.  Some of the required courses make sense. (Anatomy and physiology come to mind.)  But especially for someone who’s already got a degree, it makes little sense to require general education classes all over again — much less a physical education class.

As for EMTs. The EMT basic curriculum is way too short and way too superficial. In most places, it’s little more than teaching first aid and some basic medical knowledge. It creates people who think they’re heroes with less than 200 hours of training. We end up with people who practice medicine based on dogma and “my instructor said” and who truly believe that BLS saves ALS and they’re heroes. Meanwhile, we have more than a few places where EMTs can’t administer over the counter medicines that the lay public can and are legally prohibited from using the same glucometer that a child is taught to use.

And let’s talk about one other thing. The various ALS skill monkey levels that exist between EMT-Basic and Paramedic. These people get some or ALL of the ALS skills that a paramedic gets with none of the understanding. It’s a recipe for malpractice and for killing patients. Don’t give me the BS that it’s “for the volunteers.” There are plenty of us who volunteer who took the time and effort to educate ourselves. I’ve never worked full-time paid as either an EMT or a Paramedic and I’ve reached a decent place in the EMS world. Whether paid or volunteer, certification standards remain the same.  And allowing someone without a foundation in anatomy, physiology, pharmacology, and patient assessment to perform high risk skills like rapid sequence intubation, even with calling a physician for a radio/phone order, is a recipe for a disaster.

My solution to all of this? Enhance the educational standards for EMT-B to be more like the current AEMT. The current EMT standards should be the standard for the first responder, not one who staffs an ambulance. And I’m not sure that paramedic should be an associate’s degree. What about entering paramedic education after already having a bachelor’s degree? It’s a lot easier to teach prehospital emergency care to someone who already has critical thinking and communications skills than it is to teach critical thinking and communications skills who’s got a paramedic certification and only a vocational/technical education.

These are just my thoughts. I don’t pretend that these changes will improve EMS overnight, lower the cost of healthcare, or raise EMS wages.  What I do believe is that these are the right changes for better patient care.  And patient advocacy demands just that.

The Soft Bigotry of Low Expectations

Yes, I know that’s a quote used in a George W. Bush speech.  Yes, I know some of you may not like President Bush.  Truth be told, I don’t always either. (He’s like the Diet Coke of conservatism: Just one calorie, not conservative enough! — Apologies to Dr. Evil, by the way.)

But, truth be told, it’s a quote that applies so well to EMS.  I’ve been guilty of it myself.  And I think a lot of us are incredibly negative about EMS, our past, and our future. Day after day, I read posts on EMS social media about provider mental health.  I read posts about the pay in EMS.  Heck, I even read posts about poor EMS protocols, poor working conditions, and poor coworkers.  When you read that, it’s easy to get discouraged about EMS.

Here’s the great news.  Provider mental health is an issue.  But we’re addressing it.  The Code Green Campaign is raising awareness, promoting access to mental health care, promoting resiliency, and promoting self care.  Reviving Responders is doing similar work as well.

As for the other issues, there are solutions.  Forming associations to represent our profession at the state capitols where the majority of EMS regulation occurs is a huge step.  Yesterday marked the one year anniversary of my state’s EMS association, the Association of Texas EMS Professionals.  In that year, we’ve accomplished a lot – from providing paramedics the ability to work in hospital ERs to being recognized as the state affiliate of the National Association of Emergency Medical Technicians to being called to testify before the Texas Legislature as witnesses on EMS issues.

For those of you complaining about poor pay, poor working conditions, and poor protocols, there are services out there that are looking for EMS professionals like you.  It may involve getting out of your comfort zone, but these places exist — all over the country. At the risk of sounding like “tough love,” if you choose to still work for a bad employer, you have made your choice.

And yes, there are places where learning happens.  Social media may have its faults (see also: EMS “clickbait” articles), but the FOAM (Free and Open Access to Medical Education) movement is bringing current medicine to all of us.  Granted, much of it is geared to emergency physicians, but we should be learning at their level anyway.  Medicine is medicine.  EMS remains the only profession with arbitrary concepts like BLS and ALS.  While there may be regulations governing scope of practice, I’ll give you some free legal advice.  THERE IS ZERO LEGAL LIMITATION ON EXPANDING YOUR KNOWLEDGE.  Other learning opportunities exist at EMS conferences.  If you are only learning your profession from within your department, you’re selling yourself and your patients short.  Insular clinical thinking and inbreeding in education is a disservice to our profession.  Professional networking and exposure to new, outside ideas is how change happens in EMS.  And there’s even opportunities to expand one’s EMS horizons on Facebook.

So, in conclusion, I’ll leave you with another cliché politicized quote that also applies to what we do in EMS.  “It gets better.”  And it starts with each of us.  Go. Do. Medicine.

Have you ever noticed….?

Have you ever noticed how many new, inexperienced, poorly educated providers talk about how much they’re allowed to “do” in their EMS organization/system/region?

Today, I was involved in a discussion in EMS social media where an EMT with three months of experience was bragging about taking a sixteen hour course where he would get “training” on administering three additional medications and be allowed to use a supraglottic airway. In the grand scheme of things, all of these medications and the supraglottic airway are relatively benign interventions.  There’s relatively low risk for each of the medications and the airway device in question. What is NOT benign is the prevailing mentality in EMS that a card class or an in-service is all that’s needed, especially to teach an entry-level EMS provider skills that are normally reserved for providers with a higher certification. Even with its numerous faults, paramedic education has a depth of education in anatomy, physiology, pharmacology, and patient assessment that an EMT or AEMT course don’t have. While a sixteen hour course might be able to teach the ins and outs of those particular medications and that particular airway device, that course is zero substitute for actually having the education that an advanced provider has.  We can teach almost anyone how to do something.  Knowing when to do something — or when not to do something — is where education is superior to training.

Sadly, our profession has done little to disabuse EMS providers, especially inexperienced entry level providers, of the notion that EMS consists only of a set of skills that can be added and subtracted at whim.  Rather, like any academic discipline, particularly one involving the healing arts, EMS consists of knowledge.  And there is no statutory limit on the knowledge that any provider can have, regardless of their certification level. Professional education does not end with initial certification.  Rather, initial certification is but a determination of entry level minimal competence.  Professionalism involves the relentless pursuit of mastery well above and beyond the minimum standards.

As I’ve joked before, a cook knows and follows the recipes.  A chef understands the culinary arts well enough to be able to create their own recipes.  The majority of EMS providers are technicians — and as such, we’ve become the short order cooks of medicine.

EMS will become a respected part of the medical system when we stop talking about what we can do and start talking about what we know.  There’s a big difference between training and education.  When we routinely produce educated clinicians as opposed to trained technicians, that’s when the respect — and the money — will show up.