“Dr. Dunning, I presume?” said Mr. Kruger.

An ongoing topic of discussion on EMS social media is the Dunning-Kruger Effect.  Wikipedia defines the Dunning-Kruger Effect as “a cognitive bias wherein people of low ability have illusory superiority, mistakenly assessing their cognitive ability as greater than it is.”  Over the past few days, I’ve seen some great examples of EMS’s collective Dunning-Kruger Effect.  I also call these moments “not knowing what you don’t know” or “doubling down on dumb.”

The greatest exhibit that I can present to illustrate EMS’s exhibition of the Dunning-Kruger Effect comes from a self-promotion post by a critical care transport educator.  This educator, while promoting a post from JEMS about a Texas EMS system’s decision to adapt their protocols to prevent ventilator-induced injuries, breathlessly exclaims “ICU care begins in the STREETS! i expect my medics to be BETTER than EM and ICU attendings. ALWAYS. Period.” (Note: capitalization error was taken directly from the posting.) In the spirit of self-promotion that afflicts so many EMS “celebrity educators,” the post goes on to promote his recent conference appearances where he discussed using ultrasound to identify lung injuries and adjust ventilator settings.

Here’s the thing.  I don’t know how good or relevant his presentation is. And we all have to make a buck. And if you don’t promote yourself, no one else will.  But there’s probably not a single paramedic out there who’s better than an attending emergency medicine or critical care physician/intensivist.  Having said that and having my own experiences to guide my opinions, I will say that there are many paramedics who can assess a patient and rapidly treat a critically ill patient better than a physician without emergency medicine or critical care education.  Heck, that’s the  primary purpose of critical care/retrieval/flight paramedicine. When a patient is critically ill in a remote setting or an outlying hospital without specialist resources, that’s why you have critical care transport capabilities.

And yes, a critical care medic is probably better than an EM/ICU attending at certain technical skills.  Notice I said skills.  Most physicians don’t deal with vent settings.  Why?  Because in an ICU setting, there are others to help with such things. The physician has their eye on the big picture.  General Patton might not have been the tank driver than an individual sergeant was.  He didn’t have to be.  He did have to know exactly how to rout the enemy on the battlefield and accomplish large objectives.  Similarly, a HVAC technician probably knows more about fixing a faulty air conditioner than does a mechanical engineer. But I can almost guarantee you that the mechanical engineer knows more about how a HVAC system works and fits into a larger picture than a technician does. Likewise, I have a good friend who’s a state trooper.  I can assure you that he’s better than me, a lawyer, at knowing the intricacies of DWI law.  But he’s probably going to have a harder time putting all of the law together to get a complete picture.  Technicians, like many of us in EMS, excel at particular technical skills, hence why they’re technicians.  Professionals excel at the big picture, synthesizing multiple sources of information, acting on said information, and leading a team to solve that problem, almost like a conductor leading a symphony orchestra. (Heck, in the emergency room, look at how a resuscitation is run.  The leader, usually a physician, is rarely performing skills, but rather leading others in what needs to happen.)

Yep.  EMS often illustrates the Dunning-Kruger Effect with our belief in our own expertise.  But I can’t completely blame us.  Over the past few days, I’ve also seen ham-handed attempts by EMS educational programs to engage in education on EMS social media that illustrate President George W. Bush’s infamous question, “Is our children learning?” One community college based EMS education program shared a viral news video of a police officer being administered Narcan for an “exposure.”  Unfortunately, the initial posting by the educational program was posted without context and showed a breathing police officer being administered Narcan for a possible exposure to a stimulant, most likely methamphetamine. As even the lay public is learning, administration of Narcan is indicated for respiratory depression secondary to an overdose of an opiate/narcotic.  In other words, a conscious, breathing patient doesn’t need Narcan.  And an EMS educational program should definitely know better.

But that may not be the worst.  Late last week, a nationally known bachelor’s degree program in paramedicine shared a guest blog post from one of their students. The article was about the controversy of allowing paramedics to intubate.  Well and good.  The topic is definitely worthy of further discussion, especially considering the limited access that many EMS education programs have to clinical sites for live intubation practice. Yet, the article soon disappeared from that college’s social media.  Namely, many EMS providers pointed out multiple misspellings in the post along with dated studies cited (the most recent was over ten years old) and the lack of mention of high-fidelity simulation or more recent science supporting safe intubations through delayed sequence intubation by EMS providers.  Presumably, this blog post was reviewed and approved by the college’s faculty prior to going live. Sadly, when this kind of writing is presented by an educational institution, the writing serves only to reinforce negative perceptions of EMS by the rest of the healthcare community and remind them that the “ambulance drivers” aren’t yet at the same level.

The truth is that EMS does a good job at its core mission.  We excel at providing urgent and emergency care in the out of hospital setting and using a public safety skill set to do such. Our knowledge of the medical field is an inch wide (unscheduled out of hospital care) and a mile deep in that field.  Let’s own that field for ourselves and quit trying to prove how smart we are.  Inevitably, when we stray too far afield and when we keep calling attention to ourselves, we too often illustrate the Dunning-Kruger Effect.  These moments don’t advance EMS.  On the contrary, they remind us why everyone except for EMS providers get to make decisions about what happens to and for EMS.

 

Cleared To Practice, AKA: The License To Kill

I booted up the computer fully intending to write a long screed, aka rant, on the issues currently facing Austin/Travis County EMS, its medical direction, and their relationship with the multiple county first responder agencies and their ability to provide EMT-Intermediate, oops Advanced EMT (showing my age) and paramedic level care.  I’ll still comment on that, but in terms of ATCEMS’s model being an example of one of two extremes of the EMS field training or credentialing process.

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

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

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

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

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

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

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

EMS is OUR Profession

Here’s a great example of what’s wrong with EMS. This morning, I was looking at the webpage for the EMS For Children Improvement and Innovation Center project being administered by Texas Children’s Hospital. The webpage identified twenty-eight staff members assigned to the project.

Of these staff members, only one of them is identified as a paramedic and he’s actually a full-time employee of the state EMS office. The majority of those identified with healthcare backgrounds were either physicians or nurses. We need to quit letting EMS be defined and controlled by people who aren’t in EMS. This is the equivalent of having a bunch of paramedics define oncology care because they do transports.

The truth is that there are EMS professionals with the educational background to be involved in developing the future of EMS and determining our professional identity. There are paramedics with master’s degrees in a variety of fields ranging from the hard sciences to education to public health to administrative fields like business administration, public administration, and healthcare administration.  The National Registry even funds two EMS professionals per year to get a graduate degree in an EMS related field. There is NO reason not to have more than a token EMS presence on committees that define who we are and what we do as a profession.

Instead, through a combination of our own apathy and aggressive encroachment by other fields (cough, nursing, cough), we allow our profession’s path to be charted by those without a real stake in EMS and not necessarily with EMS’s best interests in the forefront. The nursing advocates regularly say that EMS providers shouldn’t do anything that approaches nursing and believe that nursing represents a higher level of education and skill sets.  However, these same nurses readily encroach on the EMS field and insert themselves on almost every committee that determines EMS education and practice.  Try advocating for an EMS professional to even have a seat on a committee regarding the hospital emergency department or the ICU and prepare for the wailing and gnashing of teeth.

A lot of really smart people in EMS regularly advocate for EMS being represented within the US Department of Health and Human Services.  Personally, I believe this will continue the trend of EMS having little, if any, voice of its own.  After many years as a government lawyer, I’ve realized that those who call the shots in the health and human services bureaucracies usually have a nursing and/or a public health background.  I can virtually guarantee that putting EMS in the health and human services system will ensure that nursing and public health controls who we are and what we do.  An EMS office within the HHS bureaucracy will be little more than a token voice that will be run over roughshod by the nurses, public health professionals, and various other “stakeholders” that truly have no stake in EMS.

We have got to control our professional identity and that begins with paramedics being involved in the administration and development of our profession. It’s time to demand that those that define and determine what EMS is at least have an idea of what happens on an ambulance.

Couple of Quick Thoughts

While perusing social media this morning, I noticed a couple of things that bear repeating.  Again.

The same professional EMS committee members are now taking public input on “EMS Agenda 2050.” yet we can’t always even get the core mission of EMS right — namely getting people to a hospital — ideally the right hospital and with the patient in no worse (and hopefully better) condition than we found them. I’d like to fix EMS 2018 before we turn EMS Agenda 2050 into another document forced upon us by the same people who largely created the current mess.

Everyone continues to look for a single silver bullet that will fix EMS.  Education. Increased reimbursement. The latest equipment.  Some buzzword usually involving “data.”  EMS in the United States is a local responsibility provided for in a variety of models.  Imposing and implementing one “magic solution” won’t work.  What works in a compact city like Boston with multiple academic medical centers in a small area isn’t going to apply well to rural Nevada where a small hospital is an hour’s drive.  The reason why our nation’s Founding Fathers embraced federalism is in recognition of the simple truth that one size fits all solutions from a central government rarely work. (See also: IRS, “Affordable Care Act,” and the Post Office.)

The only thing I see more than people in EMS routinely advocating for us to take people to destinations other than hospitals are stories of EMS getting refusals wrong and a patient getting sicker or dying. I say this after seeing, just this week, an article about a child whose parents called EMS to take their child to the ER for the flu, EMS obtaining a refusal, and the child ultimately dying.  Was EMS responsible?  We don’t yet know at this point.  But I do know that taking a patient to definitive care is a large part of what we do.

Most ER physicians will tell you that the hardest decision they make is the decision to admit a patient. That’s coming from a physician with access to labs and imaging and specialist consults. I’m not ready to trust someone with (at most) two years of education, minimal diagnostic equipment, and a short assessment to make the decision that going to the hospital isn’t a good idea.  Yes, there are obvious cases that we can consider “abuse” of the emergency care system. But the lawsuits will result (and they WILL happen) from the patient with vague symptoms who’s relying on the judgment of the lowest common denominator of providers who just wants to get back to their station.

And that brings me to my final thing worth repeating today.  An EMS system is only as good as its worst provider on their worst day.

Feel free to refer back to this post in 2019.  I’m sure it will remain just as relevant.

A Couple Of Reviews

In the spirit of keeping up with my professional responsibility to keep my paramedic certification up both for National Registry and Texas, I’ve been attending some continuing education lately.  As such, I thought I’d pass on a few comments about some of the hours I’ve attended in the month of November.

I was fortunate enough to attend and speak at the Texas EMS Conference in Fort Worth. Fort Worth is one of my favorite downtowns in Texas.  It’s clean, relatively compact, and there are plenty of hotel and food options within walking distance of the convention center. More importantly, the Texas EMS Conference is one of the best conference out there hands down.  The Texas conference provides up to 15 hours of continuing education over the Monday – Wednesday before Thanksgiving.  Additionally, there are preconference classes available the weekend before. The Texas conference also has an exhibit hall that rivals the two national conferences. Unlike the national conferences, though, Texas really strives to educate attending EMS providers. While Texas presents a few of the usual national conference speakers known more for entertainment than educational content, the Texas conference really strives to educate and highlights quite a few local providers and educators whose content is first rate.  This year seemed to have even more of a focus on care under fire, with presentations by Fort Worth police officers, a trauma surgeon who responded with the Dallas Police Department to mass shooting in downtown Dallas, and a former Army Ranger physician assistant now attending medical school.  Unlike many conferences, these presentations on care under fire were thoughtful and heavy on current medicine — and with very little emphasis on “heroism” or the “thank you for your service” mindset that often permeates the EMS community.  Truth be told – the Texas conference is a great bargain for a phenomenal mix of continuing education and networking. Additionally, both downtown Fort Worth and the Stockyards district offer some great food and entertainment venues, including Texas music and food.

On a different note, I needed to knock out a half hour of continuing education on anaphylaxis for my National Registry Paramedic certification. I decided to find an online resource to count for this.  And in the end, I made a huge mistake. I decided to use JB Learning, who offers a half hour online class on anaphylaxis. The course material itself, even though billed for advanced life support providers, was beyond basic.  There was heavy emphasis (and rightfully so) on the use of epinephrine.  There were brief mentions of nebulized bronchodilators and intravenous fluid boluses.  And zero mention of an antihistamine such as diphenhydramine (Benadryl), let alone a H2 blocker as some clinically aggressive EMS systems use — and as supported by evidence.

If that was the only issue, I’d shrug my shoulders and just accept the danged half hour of continuing education and move on.  But the platform itself is beyond miserable.  JB Learning now markets all of its continuing education, even when sold separately, through it’s “Recert” platform, which is marketed as a one stop solution for EMS providers’ continuing education and tracking. (Truth be told, keeping up with your continuing education is a basic responsibility of being licensed in any profession. If you need that much help in tracking your hours, I’m not sure I want to trust you with the responsibilities of being a healthcare professional.) So, in short, you pretty much have to use JB Learning’s “Recert” platform.  And that platform requires a skills verification — which isn’t mentioned until you’re into the course.  After a bit of consulting with tech support, I’m not sure whether this half hour is or isn’t going to work for me, especially since I haven’t been able to go back and download the skills verification, which supposedly I’ll upload and then, in theory, get a certificate.

For years, Apple prided itself on the slogan “It just works.”  To my friends at JB Learning, who are trying to market themselves as a one stop solution for both initial and continuing education for EMS professionals, “It just works” doesn’t apply to y’all yet. On the positive note, I’m only out $6.95.  On a negative note, I’ve spent more than the half hour of continuing education in terms of getting a certificate for continuing education credit — and I still don’t have one.  As the old adage says, let the buyer beware.

The Challenge of EMS Conferences

I attended EMS World Expo last week in Las Vegas and had a good time.  I had the opportunity to reconnect with several of my good friends in the Las Vegas emergency medicine world.  I got to see a bunch of people who I only see at these conferences and meet several people who I previously only knew through the Internet. And I ate like a king.  (If you know me away from the blog, you can easily find my Yelp reviews with some incredible food suggestions for Sin City.)  And being as it was Vegas, well, I had fun in Vegas.

But here’s the sad, but honest truth.  I learned very little.  I did come away with one huge new thing — apparently, there’s now an EZ-IO placement in the distal femur for pediatric patients.  But the rest of the presentations were pretty “ok.”  There’s not a lot of new information out there.  And sadly, in a presentation on recent research, a renowned EMS scholar presented information on fluid resuscitation in sepsis that is not only not current, but may even be contraindicated by more recent research.  Sadly, some of the best airway education was occurring in the exhibit hall practicing the SALAD technique with disciples of anesthesiologist and EMS airway physician Dr. Jim DuCanto.

I wasn’t going to gripe about this until seeing my friend and EMS airway ninja post some excellent education online regarding surgical airways and the need to rapidly move to a surgical airway. I asked myself why a presentation like this didn’t occur at a major EMS conference.  I came up with three reasons.

  1. Audience.  Truth be told, not everyone in EMS wants to learn the most current medicine.  There’s a large, loud contingent of folks who want to learn the bare minimum to maintain certification and/or pass the test. “Meets minimum standards” is a mantra in EMS.  And as we’ve all heard me gripe before, you can never go wrong in overestimating the number of people in EMS who are in it for the hero status as opposed to the medical professional status.  See also: EMS t-shirt sales.
  2. EMS celebrities. Truth be told as well, there are certain speakers on the EMS conference circuit who are known quantities.  They’re entertainers first and educators last.  They fill the seats and are like flypaper attracting the “meets minimum standards” crowd.  These people can speak on any topic, present dated or questionable information, and have limited expertise on the topic.  But because they’re funny and/or appeal to the lowest common denominator, EMS conferences continue to invite them as speakers.  Why?  Because they put butts in the seats.
  3. Timing. Most of these conferences put out calls for presentations almost a year before the conference commences. As such, the most current research and practice doesn’t always make it in time.

If you wonder why I spend so much time on EMS social media and blogs, I will close things out with a quote from Dr. Joe Lex, the intellectual godfather of #FOAM.

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 if you don’t know #FOAM, it’s likely you’re already a step behind the EMS education curve.

What’s Wrong

This morning, I received a long email from a long-time mentor of mine who’s also a paramedic and attorney.  He was pretty upset about the lack of involvement from physicians in improving the state of EMS.  As I replied, I realized that I needed to adapt my reply to share with my three or four devoted followers.

I blame the docs too, but only tangentially.  They write protocols for the lowest common denominator.  They are risk averse and rightfully so.  There’s a lot of good paramedics out there, but there’s even more who shouldn’t even be trusted with a BVM (which I still think is the most dangerous and under-respected tool on the ambulance).  It goes back some to education.  We have way too many people teaching EMS education whose only expertise is that they hold an EMS certification. Law school and medical school aren’t taught the entire way through by the same someone with a JD or MD.  There are multiple classes, each taught by subject matter experts.  One of the things I hear from some of the EMS dinosaur types is how some of their classes were taught by physicians (including specialists) and nurses.  We don’t have that anymore and I think the education has suffered as a result.  CoAEMSP doesn’t care. They care that you’re using FISDAP or “Platinum Planner” to track your students and develop more metrics. They don’t care about the quality of the content.  NAEMSE doesn’t care.  They are too busy promoting “flipped classrooms,” “learning styles,” or whatever other trendy topics are out there.  The NAEMT doesn’t care.  They’re too busy promoting new card courses to cover things that should’ve been covered in initial education.  The American Heart Association doesn’t care.  They’re too busy promoting ACLS, BLS, and PALS to care.  And the NREMT?  They should care, but they don’t.  They will get the usual professional EMS committee members in a room and issue high and mighty statements about the EMS Agenda Version Whatever.  And the item writing committees for the exams will give a de facto veto to the state with the worst EMS standards because the exam “has to reflect the entire country.”  And the publishers of EMS texts don’t care.  They know their market.  Truth be told, there’s more people reading at a tenth grade reading level who are getting their paramedic because their fire department requires it than there are students (or teachers) who really want to understand the whys of prehospital medicine.  And the students and educators that do want to know how to practice prehospital medicine are supplementing their texts with medical and nursing texts as well as online material. The state health bureaucracies don’t care.  EMS is a small part of their mission.  They see their mission as public health and welfare — and to the average bureaucrat with a RN and a MPH degree, EMS is best seen and not heard — and then, only seen during EMS Week.  The Feds?  Well, truth be told, EMS really isn’t a Federal responsibility and making it such will ensure that the same people who brought us the VA will be in charge of prehospital medicine as well.
And don’t even get me started about the usual gang of idiots.  In short, every EMS committee is tasked to solve the ongoing problems of EMS but is full of the same EMS celebrities who created the problem in the first place.
EMS as a whole is beyond repair.  But virtually no single EMS system (except maybe perhaps some of the large urban systems) is beyond salvage.  Fix each system and fix the individual EMS education programs and eventually, the rising tide will lift all boats.
Until then, rant globally, fix locally.

Bread And Butter

Today’s blog post (and sorry for the delay to my Mom and the two others who read the blog) was going to be about continuing education.  I was going to write about the seeming inability to get the majority of EMS providers to engage in continuing education above and beyond the usual “required” card courses and/or the state-mandated refresher course material.  (Parenthetical.  I’m very glad to practice prehospital medicine in the Lone Star State where the state mandates very little as far as specific content and leaves it up to the provider as to what continuing education to seek out, subject to a few broad categories.)

I was going to complain about people not attending high quality continuing education, even when it’s offered for free.  I was going to mention the challenge of bringing the knowledge from international and national conferences like SMACC and EMSWorldExpo back to one’s home EMS system.  I was going to mention what I call the “Goldilocks” challenge of EMS continuing education — ensuring that the material isn’t so introductory to be a rehash of EMT classes but isn’t so complex as to require a PhD in pharmacology and physiology to understand the material, let alone apply it. I could even mention the whole volunteer versus paid debate, not even mentioning how so many volunteers manage to attend outside continuing education and conferences on their own dime, but you’ll rarely see a large EMS system (let alone a fire-based EMS system) sending people to a conference, let alone their members attending on their own. (See also: If I need to know it, they’ll do it in-house and pay me overtime for it.)

These are all worth mentioning.  And they deserve mentioning.  But here’s what really struck me. We can have all of the high-speed providers going to courses like these.  And there’s also going to be a lot of people going to “cool” sounding continuing education courses in tactical medicine, hazmat, or some sort of technical rescue. (Please, please tell me why an EMT working interfacility transfers needs to know how to be an “operator” in the hot zone.) But we rarely have good, consistent, clinically current, relevant continuing education on the topics that are the bread and butter of prehospital medicine. Think about your last shift on the ambulance.  Chest pain, respiratory difficulty, sepsis, ground level falls, abdominal pain, routine MVCs.  How much continuing education have you received on these matters? If you did receive continuing education on these topics, was it merely a repeat of what you’ve been told every recertification cycle you’ve been in EMS? From the amount of providers who think that any heart rate above 120 must be some form of arrhythmia that requires treatment and who think that EMS administration of diuretics for CHF patients is a good idea, clearly, we’re not getting the bread and butter of EMS down, much less mastering it.

What we see with continuing education is but a symptom of what’s wrong with EMS.  We want to do all the new cool things of the moment, whether it’s community paramedicine, technical rescue, tactical medicine, or critical care medicine.  We don’t want to do the bread and butter of medicine (see also: every EMS social media forum complaining about system abuse, drug abusers, or “frequent flyers”) and when we do the bread and butter, we aren’t always current.  If we can’t get the routine right, why should we be trusted with thinking outside the box?

The Access To Knowledge

One of the greatest things about the Internet is that it has democratized access to information.  Most academic journals are available online, some of which are even available for free.  Wikipedia has improved, in most cases, to provide reliable information on most subjects.  There are plenty of other sites that provide scholarly level information out there.  Then there are sites like Khan Academy that make basic education in a variety of subjects available for free.  And if you can’t find the information online, you can order virtually any book online through retailers like Amazon.

In other words, you can have access to the same educational materials that train professionals in any field.  Want to learn gastroenterology?  The books used to train residents and fellows can be ordered online.  Want to learn engineering?  The materials are available online too.  Want to be an administrative lawyer?  Yep, law can be found online too.  You can find most legal codes online and with a bit of searching, you can even find the relevant cases too.

Here’s what none of these books will teach you.  They won’t teach you the mindset of how to think like a member of a profession.  The materials alone don’t teach the academic or professional discipline. Reading statutes, regulations, and cases may provide some insight on the law, but you won’t necessarily grasp the legal principles or reasoning, much less how a single law in and of itself interacts with all of the other laws out there.  Likewise, one can buy all of the cardiology texts out there and become quite knowledgeable about the heart while at the same time failing to realize that the heart is but one interdependent organ in an entire human body.

The democratization of information has done wonders for our society.  Yet, one of the biggest challenges is that mere access to information doesn’t necessarily mean understanding the information.  Nor does it mean placing said information into its proper context.  If you don’t believe me, look at the number of self-appointed experts who have “done their research” posting online. Cherry-picking from a discredited study doesn’t make you an expert on autism and vaccines. An undergraduate degree combined with a medical degree is where you learn to skeptically examine scientific claims, understand how the human body works, and put that knowledge together to treat patients. Likewise, merely cutting and pasting a statute that you found via Google doesn’t make you the next Clarence Darrow.  As much of a cliche as it is, “learning to think like a lawyer” is exactly what law school does — teaching legal research, teaching legal writing, and ultimately, teaching enough legal reasoning so that you realize that a case is rarely won by merely cutting and pasting a statute in and of itself.

Information is great.  Education is more than information.  Education is the process of learning how to process, synthesize, contextualize, and use the information outside of a vacuum. And that’s why there’s such a market for the coffee mugs that say “Don’t confuse your Google search with my professional license.”  Whether it’s an EMS certification, a professional engineer’s license, or a subspecialty in medicine, thinking that reading the books and journals on your own makes you the equivalent of a licensed professional is hubris to the point of danger.

How does this apply to my usual writing about my self-described expensive hobby of EMS?  Quite simply, our field has a fair amount of self-appointed experts in anything vaguely and tangentially connected to EMS.  While there are many in our field who worship at the altars of dogma, vaguely defined “experience,” and the even worse defined “how we do it in the field,” probably the most dangerous are so-called leaders in our field who routinely opine on subjects in which they have knowledge, but not the education to contextualize, synthesize, or harmonize the knowledge outside of what they just read and parroted.  If you don’t believe me, look at how many places immediately remove (or add) an intervention or medication based solely on one article that’s been making the rounds of the EMS community.

In conclusion, the summation of human wisdom in any field is rarely going to be found in a Facebook post or a blog post.  As the Romans would say, “caveat emptor.”  As Reagan would’ve said, “Trust, but verify.”

Another Part of Being a Professional

Social media is the gift that keeps on giving for an EMS blogger.  It enables me to amplify my voice.  But today, it keeps pointing out something so obvious about why EMS still isn’t taken as a profession.

Plain and simple, part of being a professional, whether it’s nuclear engineering or being an EMT, means being responsible for your own learning. There are conferences, internet resources, journals (real journals, not trade publications), and even books that exist to expand your knowledge of all things about the delivery of prehospital medicine. Yet, there’s all too many in EMS who view social media as the equivalent of “phoning a friend” or “asking the audience” in a virtual EMS game show.  (Or maybe it’s the EMS Gong Show?)

While perusing EMS social media today, I’ve seen basic questions about how to recertify, how the National Registry exam works, and basic cardiac arrest management.  I’m far from the sharpest spoon in the drawer of EMS silverware, but I found the answers (and from reputable sources, no less) to these questions with a quick Google search. This leads me to one of several conclusions.  One, there’s a significant portion of people in EMS who are incapable of performing even basic research. Two, there are people who expect the answers spoon-fed to them.  Or three, they want someone to hold their hand and merely validate the belief they already hold.  None of these alternatives are promising for our profession’s long term viability.

As the bachelor’s degree has become the de facto standard for nursing, we continue to turn out a significant portion of so-called heroes who have no use for so-called “book learning” and believe that real learning only occurs on the “streets.”  And we wonder why the Los Angeles Fire Department is using nurse practitioners for community paramedicine?