Yelping The Eagles

Anyone who knows me knows that as much as I love EMS and law, I also enjoy good food and have a tendency to write reviews of good (and occasionally bad) food on Yelp.  This weekend, I’ve attended the Gathering of Eagles conference in Dallas.  Seeing as Yelp probably isn’t the forum to review the Eagles, I’ll blog my review instead.

Sum total 4/5 stars.

This was my first time attending the Gathering of Eagles conference, but it will definitely not be my last.  This is unlike virtually any other EMS conference.  First, the presentations are exceptionally short.  For many of us, it’s perfect for short EMS attention spans.  For others, the presentations are just enough to whet your appetite to dig deeper into the subject.  For some of those subjects, I’m probably in the latter.  Other subjects were brief enough so as to not lose my interest.

I also appreciated the value for the money.  For the cost of admission, you get two days of continuing education as well as continental breakfast, cold drinks during the day, and lunch both days.  I can’t think of any other conference that delivers that kind of value.

The other huge positive to Eagles is the accessibility.  Each of the physicians readily made themselves available to the audience for questions immediately after their presentation and around the conference.  In fact, at the lunches, the conference organizers made an effort to have an “Eagle” physician at each table.  The opportunity to talk informally — and learn — from some very respected physicians rarely presents itself this easily.

The final advantage to this conference is that the audience largely selects itself.  This isn’t a conference designed for the average provider.  It’s heavily science and research driven.  There’s quite the smattering of medical students, residents, EMS fellows, and physicians in the audience as well as senior EMS management.  There’s not a finer networking opportunity anywhere.

There are two caveats to this conference, although they’re nowhere enough to discourage attending.  First, with the heavy focus on research, there’s a strong emphasis on cardiac arrest and resuscitation.  In other words, dead versus not dead is easy to measure.  Second, the Eagles represent very large EMS systems.  These systems, by their very nature, are large urban systems.  Their models of care don’t necessarily easily translate to smaller systems where changes can be rolled out more quickly to a smaller number of providers.   In other words, not all that is presented here will be new to providers in more progressive or aggressive EMS systems. (Perhaps there’s a need for a separate conference with the physician medical directors of suburban and rural EMS systems.)

Having said all of this, I will definitely be back next year.

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.

Gresham’s Law and EMS Social Media

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

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

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

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

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

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.

To The EMS Students And New Providers

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

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

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

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

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.

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.