Your Internship in EMS

Some of my best ideas for discussion fodder come from EMS social media.  Both the great insights and the “what was that guy thinking” moments get me to thinking about EMS and how we can “Make EMS Great Again.”

Today, several discussions led me to the topic of today’s blog entry for y’all.  A good friend of mine was bemoaning the lack of critical thinking in EMS providers of all levels, particularly after reading yet another “experienced” paramedic say the worn out, discredited, incorrect cliché of “BLS before ALS” yet again.  He suggested a need for an assessment and scenario based class on critical decision making, especially in relationship to airway management.  Another smart paramedic commented on a need for a course in scene management.  A few short moments later, I got an email advertising a textbook for a new NAEMT “card course” on “EMS Vehicle Operator Safety.”  And several days prior, people were bemoaning the current state of EMS continuing education where mandatory “card courses” like CPR and ACLS are virtually impossible to fail, yet also devoid of much educational value.  Then, there are all the new “tactical” classes for incidents unlikely to occur in your jurisdiction. Meanwhile EMS continuing education fails to keep providers current on the science and treatment of “bread and butter” EMS calls like respiratory distress, chest pain, abdominal pain, and routine trauma.  But there are certifications for critical care medicine, flight medicine, tactical medicine, and community paramedicine.  Before we reboot into EMS 3.0, let’s try to make sure that EMS 1.0 isn’t a completely flawed platform.

And then, all of these thoughts combined as I realized that they all, in part, address the same challenge. Namely, the idea of a “street ready” paramedic doesn’t exist. The National Registry exam, by its own admission, measures minimal entry level competence to safely practice.  Most organizations have some sort of field training process.  In these organizations, they usually run between one of two extremes. Some sort of quick orientation process that exists solely to say the new hire was “checked off” or some sort of extremely long process that is a virtual repeat of your EMS educational program’s clinicals where you are evaluated on clinical proficiency in each and every skill.  And in all too many programs, the FTO process becomes a legalized hazing process where you perform to your FTO’s prejudices, biases, and whims. Having been through a variety of field training programs, I can say that what doesn’t exist is an orientation to things you might experience daily — how to use the two way radio, how to troubleshoot various pieces of equipment, how to get supplies, etc. And depending on where you’re employed, you may go weeks — or years — without being exposed to certain types of calls and patients to put in your personal library of encounters that you can call upon for the next patient care challenge.

As a new lawyer, I experienced many of the same frustrations.  I came out of law school and the bar exam supposedly “ready to practice law.”  But my first few years as a lawyer, I was really learning how to practice law. And I began to recall something that was discussed in law school – namely, there is no internship or residency for lawyers like there are for physicians.

As a paramedic who didn’t have to rely on a paycheck as a paramedic, I got lucky.  I worked part-time for a while for a suburban service as I realized how little I actually knew.  I then got VERY lucky to find a volunteer position with the service that made me the paramedic that I am today — Harris County Emergency Services District 1 (now called Harris County Emergency Corps).  I walked into a perfect situation.  At the time, the District utilized their volunteers primarily as third crew members on a truck.  The paid staff usually appreciated an extra crew member to help.  And there were plenty of crew members who were willing to take the time to teach and pass on lessons.  It also didn’t hurt that the District was like the Bermuda Triangle of EMS.  Calls happened at HCESD-1 that simply didn’t happen anywhere else. High acuity calls in an economically depressed inner city combined with access to the best hospital systems in Texas made this an ideal learning environment for a motivated paramedic wanting to truly learn their craft.

In other words, I walked into, without realizing it at the time, a virtual internship and residency in urban EMS.  I remain convinced that my three years there made me a competent, motivated paramedic.  I actually even remain in contact with several of my former colleagues.

I realize that the funding issues and operational issues remain out there, but don’t we owe it to our patients, and even more to our professional identity, to create paid internships and residencies in EMS where a new paramedic has a safety net of experienced providers to work with in the right environment to truly become a master clinician?  Clearly, what we’re doing now is window dressing.

An internship program for EMS would create truly “street ready” paramedics.  Having an opportunity to truly learn medicine, both clinically and operationally, functioning as a third crew member with an experienced mentor (NOT a FTO “checking you off”) in a high volume system would be a perfect transition from student to employee.  If we can continue to tilt at windmills in EMS, like the quixotic quest to declare EMS an “essential government service,” why can’t we decide that we want providers who are truly ready to practice?

Let’s make the commitment for some high volume systems to serve as true training grounds for new paramedics to earn their spurs.  It’s time.

The Quest for Balance in EMS Social Media

For those of you who know me outside of this blog, you may know that I run several EMS groups on Facebook. Several are private groups for friends and colleagues, but one group has grown well beyond expectations.

Running an EMS page on social media is a constant challenge.  I like to compare it to Goldilocks and her porridge tasting. Some porridge is too hot. Some is too cold.  She had to try to find the right porridge.

EMS social media is the same way. There’s one extreme where we always have to be supportive. Everyone should follow their dream and passion to be in EMS, even if you’ve failed the National Registry exam three times.  These people recite the dogma quotes we all cringe at. “BLS before ALS.” “EMTs save paramedics.” “Race the reaper.” Their sources of information include “my instructor told me” and “our protocols said.” If you challenge these folks, you’re automatically unsupportive and get called a “paragod.”

There’s an opposite extreme as well.  These are the people who obsess and drone on about arcane clinical topics.  No minutiae of biochemistry or pharmacology is too obscure for these pedants to emphasize that you’re “dangerous” if you don’t understand.  These people, or their companions, like to post random EKGs with subtle findings that even cardiologists would debate.  They will post these EKGs without any patient presentation and expect any EMS provider to find the zebra or risk their scorn and ridicule.   It’s as if Sheldon and the rest of the cast of The Big Bang Theory started working on an ambulance and/or as EMS educators.

So, there’s a balance.  The truth is, it shouldn’t be that hard to pass an entry level EMS exam which measures minimal competency.  Mere certification determines entry level competency.  We must always strive to be better, each and every day. It’s my personal belief that EMTs should be reading paramedic level material for continuing education and/or possibly considering pursing AEMT/Intermediate or paramedic certification.  It’s my belief that paramedics should be reading physician-level educational material to supplement their knowledge. With the advent of open learning sources such as FOAMed and the like, the material is accessible.  However, it’s also important that we remember our fundamental role in the world of medicine. In most cases, we are the entry into the healthcare system.  If we can get the right patients to the right level of care the vast majority of the time, then EMS is a success.  Don’t worry about the Krebs cycle nearly as much as you worry about taking care of your patient.  I don’t expect the average EMS provider to provide physician level care or have a PhD’s understanding of the underlying science.  I expect competent, compassionate care where a clinician recognizes their limits, but challenges themselves to expand those limits daily.

Medicine is a parallel to engineering.  While both are based on the sciences, they are the application of pure science to solve human problems.  Never forget that what we do is about people.

Having said my peace for now, I make one promise to you.  I’ll try to be a better clinician, caregiver, and person today than I was yesterday.  I merely ask that if you share a passion for EMS that you make the same commitment.

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.

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.

What Might Be Wrong With EMS and EMS Education

Earlier this week, I was speaking with someone in the EMS regulatory world and they mentioned having to possibly roll out a class on a new infectious disease concern.  I began to wonder if part of the problem is that many EMS providers are technicians who are taught to “fix” a patient’s “condition.” Every so often, the latest buzz hits EMS and we all roll out something “new” to address this.

Some years, the EMS flavor du jour is anaphylaxis.  Some years, it’s been cardiac arrest.  Some years, it’s been acute coronary syndrome.  Yet other years, stroke becomes a focus. Currently, we seem to be torn between sepsis and emerging tropical infectious diseases (Ebola and now Zika).  All of these are important topics and something that any EMS provider should be capable of at least beginning to address. Meanwhile, we have all of the various factions advocating that EMS will get the respect it deserves if we go into “community paramedicine,” “tactical medicine,” or “critical care paramedicine.”  Then factor in the various advocates pushing differing models of EMS, whether private, third-service, or fire-based.

Yet, what everyone is overlooking is simple. We’re teaching EMS providers the recipes for cooking, but not how to actually cook.  Every one of these new ideas that rolls out fails to address the simple fact that EMS providers aren’t taught the fundamentals of medicine.   Teach anatomy, physiology, pathophysiology, pharmacology, assessment, and skills appropriate to the provider level.  If you taught the core fundamentals of medicine rather than flowcharts and protocols, you’d have an educated provider who, at any level, is capable of adapting and providing clinically appropriate to almost any patient.

If you teach a chef, you teach them their way around the kitchen.  If you train a cook, you teach them how to make things from the recipe.  In EMS, we’re turning out short order cooks who need a new recipe anytime the clinical tastes change as opposed to professional chefs who know how to make a recipe of their own and can vary that recipe for their patient/customer. And until we fix that, all of the latest card courses and “urgent” continuing education modules to address the latest problem won’t fix the real problem with EMS.


It Depends

Anyone who knows me in real life or has heard me talk about the law has heard me say that the lawyer’s favorite answer to any question is always, “It depends.”

In the law, we have a lot of sayings.  “Bad facts make for bad law.”  And another favorite question of mine is “What does the contract say?”  These sayings, among many other legal maxims, recognize that answers to most legal questions are nuanced and there are many variable factors in answering the question, including the facts underlying the matter and the law of the jurisdiction.

Yet when I switch roles from lawyer to paramedic, I never cease to be amazed by the number of EMS providers who want hard and fast answers to complex medical questions.  They want an “If A, then B” approach where their ability to make decisions is binary (yes/no), as opposed to providing for nuance and judgment.  The answer in almost every scenario facing a medical provider is incredibly dependent on many subjects, including provider skill, patient presentation, access to definitive (and appropriate) care, and availability of resources. In other words, what works in rural Nevada doesn’t necessarily apply in downtown Boston.  And one rightfully expects different measures to be taken based on patient presentation.  It’s really short-sighted and dare I say, ludicrous, to expect complex questions to be answered with simple linear yes/no answers.

Part of being a professional, in any field, including EMS, is that we embrace nuance and subtlety in our practice.  By embracing the fact that uncertainty and nuance enhance what we do, we become professionals.  By demanding a liner flowchart, we remain technicians.  And ultimately, it remains my core belief that EMS providers are, even in a limited way, engaged in the practice of medicine. Practice your profession.

Test Prep or Understanding?

Confession time here.  Last week, I took the CCP-C exam and it kicked me in several places.  In all honesty, I was pretty arrogant to think that I might know enough critical care paramedicine to pass the exam without having had the benefit of a critical care course.  Having said that, I did come closer to passing than I probably should have.

Upon reflection though, I realized the real mistake I made.  I listened to some of my friends who said that going over the various test prep books and programs would be sufficient to get a “smart guy like you” through the exam.  I spent a fair amount of time in these books and the websites and still came away a bit short.  What I didn’t spend the time doing was actually learning the material and gaining mastery of it.  Instead of practice questions about vent settings, lab values, and hemodynamic monitoring, I should’ve been learning those concepts frontward and backward.  It wasn’t the cheapest exam by any stretch.  But I think I got a very inexpensive lesson in doing the right things for my professional development and for my patients.

The practice of medicine is not merely passing a test.  The tests occur every day with each of our patients.  We owe it to them and ourselves to master our knowledge base and keep expanding our knowledge base.  Reality isn’t a multiple choice exam.  Our real test occurs when the pager goes off and we get sent into the unknown.  Whether it’s the medical first responder exam or board certification in a physician subspecialty, an exam measures entry level competency.  Let’s stop preparing to be merely entry level competent.  Let’s start preparing to be the masters of our profession.

EMS will be a better place and we’ll have better providers when we stop hearing about the exam and the “tricks” to pass it.  Instead, we should start worrying much more about comprehending the underlying material that’s on the exam. Of course, mastery of the material is much more complex than merely regurgitating crammed material for a multiple choice exam….

As for me, I’m going to retake the exam eventually, but not until I’ve read and understood critical care medicine from a physician level text on ICU medicine. Why?  Because I don’t get multiple choice options in real life and I’ve yet to be able to choose which patients I get.


Online EMS Learning

EMS social media, whether it’s a blog, podcast, or even a Facebook page, has greatly improved and democratized the access to advanced knowledge in EMS.  The ability to hear about and learn from renowned clinicians and educators and to become rapidly informed on cutting edge research cannot help but improve the average EMS provider’s knowledge base and clinical abilities.

Having sung the praises of EMS social media, I’d share a few warnings, though.

There are a lot of people NOT to learn from.  Namely, there are the pedants out there who know the minutiae of medicine.  These people rarely put things into proper perspective.  For the newer or less confident provider, the only thing they offer is self-doubt and a loss of confidence. We all have to walk before we can run and the social media pedants often forget that.  A newer EMS provider may well not know subtle EKG changes or the minute details of pharmacodynamics of a medication.  Overwhelming them with information may cause the newer provider to run away and retreat into a mindset where they believe themselves to be an inadequate provider as opposed to a provider who’s not necessarily been exposed to the concept(s) in question. The EMS pedants rarely account for the experience level of the provider or the relevance of the information to EMS practice.  Rather, everyone who doesn’t master knowledge to the level of the EMS pedant is dangerous, incompetent, and quite possibly doesn’t even like kittens, puppies, and pizza.

You’re going to make mistakes.  The truth is that in medicine, unlike the social sciences, there are answers that are wrong.  It’s ok to make mistakes.  The critical step is to learn from the mistake.  Some of us on EMS social media, including me, engage in Socratic dialogues designed to educate and help you learn the fallacies and errors of your position. It’s rarely personal, but rather a way to educate.

On a similar note, expertise IS often a substitute for experience.  Someone who’s a physician is going to have a much better understanding of medicine than a new EMT.  Likewise, someone who’s an attorney with prehospital medical experience is likely to have a deeper understanding of the law than someone whose legal education consisted of having a PowerPoint presentation read to them.  Just like there are wrong answers, there are also people whose expertise and education give them more credence.

In medicine, as in the rest of the professions, there are few absolutes. And the more education one acquires, the less definite the answers become.  The absolute rules hammered during a 180 hour EMT course become increasingly nuanced with more education and experience. I’ve always said that, in law, the answer is “it depends,” primarily because of the facts of a case and the laws of the relevant jurisdiction.  In emergency medicine, “it depends” is often true — unless you’re an entry-level student or provider who hasn’t acquired the education or experience to appreciate nuance.  In those cases, the answers are always absolute and based on dogma.

So, my advice?  Get involved in EMS social media.  Get messy.  Make mistakes.  Engage in the dialogue. As the saying goes, good judgment comes from experience.  And experience comes from making bad judgment calls. For me, I know I’ve made countless friends, acquired a few mentors, and learned lots.  I hope it’s the same for you as well.

It’s Registry Renewal Season

And that means everyone is scrambling to get their continuing education hours in.  (For the record, mine are done, paperwork is in, and Registry is renewed for another two year cycle.)

But this got me to thinking about continuing education. There seems to be a real conflict between continuing education and refresher.  Refresher, at least to me, means a review of previously obtained knowledge.  Continuing education, at least in the professional world, implies education designed to expand on previously obtained knowledge.  In other words, you’re supposed to be learning about what’s changed in your profession.

And there’s the conflict.  Too many of us in EMS see maintaining our certification as merely maintaining our current knowledge base.  And it’s so easy to do with a recertification process that makes it easy to take the same card courses and even the same continuing education courses year after year.  In fact, if anything, the current process means its actually less of a headache to take card courses than to find the exact courses you need to cover the relevant topics for the refresher requirement.  And for most of us, present company included, that’s often a headache we don’t want to deal with.

My solution?  Simple.  Let’s have a short refresher course on high-acuity, low-volume skills coupled with an update on core topics in EMS care and mandate actual continuing education that expands on, rather than repeats, initial EMS education. There should also be a requirement that continuing education hours not be repeated in multiple renewal cycles.  Further, I believe that certain infrequently practiced skills (e.g.: intubation) should be refreshed in a skills lab or clinical environment. (Speaking of which, wouldn’t it be incredible if we had a process for currently certified EMS professionals to go back into a clinical setting to get additional exposure to certain skills to maintain mastery?) And as convenient as it is to have all of the continuing education done in house, it also creates an environment where the education and the presenters become stale.  Take the time to truly expand your knowledge base by expanding where you get your continuing education, whether it be from another EMS organization or an EMS conference.  While you may not get extra hours of credit, the expanded networking and differing views are guaranteed to make you a better provider.

It’s time for medics renewing their certification to be learning about current medicine rather than rehashing dated medicine — or worse yet, dogma.

Opining on Protocols

As Bill O’Reilly says, if you must opine, keep it pithy.  I may not be pithy, but I must opine.  Lately, I’ve noticed a recurring trend on EMS social media when discussing protocols.  Namely, people are convinced that deviating from protocol makes you immediate prey and fodder for attorneys.  Well, that’s simply not true.

Here’s some good news.  First, most attorneys aren’t that interested or knowledgeable about EMS and what we do.  Second, while deviating from your protocols may well get you in trouble with your medical director and/or your bosses, it’s not going to make you automatically subject to a lawsuit.

Let’s discuss that a bit further.  Most claims against EMS for a bad outcome are going to be based on negligence.  I’ve discussed negligence before, but as a reminder, the four elements are a duty to the patient, a breach of that duty, causation of harm, and damages.  So, in order to prove a negligence claim based on a breach of protocol, one must first prove that deviating from protocol breached the duty to the patient.  In other words, the plaintiff is going to have to prove that the protocols represent the current standard of care.  In many cases, many EMS systems have outdated protocols that do not represent the standard of care.  For example, look how many EMS systems still backboard the majority of trauma patients or require high-flow oxygen for all patients.  In the case of high-flow oxygen for cardiac and stroke patients, the current science in fact reflects that high-flow oxygen actually harms patients. Next, the plaintiff will have to prove that the deviation from protocol caused harm to the patient and that the harm caused damages.  That’s a high burden to overcome.  In other words, the plaintiff is going to have to prove that what you did or didn’t do was the reason there’s a bad outcome.  Especially in critical or high acuity patients who had a bad outcome (IE, death), there’s often an argument to be made that, no matter what EMS or other medical providers did, the patient might have died regardless.  The reality is that we just aren’t going to get every patient back.

And let’s consider one other thing about protocols. Sometimes protocols are blatantly wrong and following them is just as wrong.  Let’s pretend that your protocols suggest you administer a clearly incorrect dose of medicine.  Blindly following them does not shield you from liability.  As a trained medical professional (which is what we’re all striving to be), you have an obligation to clarify and/or refuse to follow a clearly wrong order.  The “just following orders” defense went out with the Nuremberg trials at the end of World War II and remains just as legally and morally invalid as it was then.  If EMS providers want to be considered as the professionals we should be, then we can’t hide behind the doctors’ lab coats when we’re practicing medicine that is clearly wrong and/or harmful.

Of course, nothing here constitutes legal advice.  I’m just trying to clarify and educate here.  If you’re that worried about the attorney boogeyman, your time and money would be better spent on buying EMS professional liability insurance and/or consulting with a lawyer admitted to practice in your state.  Sadly, I’m afraid that some of the people most worried about the legal boogeyman would rather spend their time repeating legal myths and dogma they heard third or fourth hand in a war story during their initial EMT class’s medical legal lecture.

In conclusion, the law is a complex and nuanced topic that is dependent on the statutes and case law of the particular jurisdiction as well as the facts of the case.  That’s why those who’ve attended their one mandatory medical legal class have absolute certainty in their wrong answer and why attorneys with three years of law school after four years of undergraduate education say, “It depends.”