The Semi-Regular Reminder on EMS Politics

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

 

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

 

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

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

 

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

What Really Happened With The Proposed Sale of AMR

A friend and fellow blogger recently posted a blog where he lays the blame at the Trump Administration for the possible sale of AMR due to the possible repeal of the Affordable Care Act, AKA “ObamaCare.”  While it’s certainly trendy to blame President Trump, Republicans, and Russian hackers for everything (and I blame them for my breakfast tacos being fouled up), I offer a more reasoned analysis that lays the blame right back it should lay — at the feet of the management of Envision Healthcare, AMR’s current parent corporation.

In my opinion, Envision Healthcare and AMR engaged in two critical failures that continue to haunt EMS.

First, we in EMS like whatever is new and trendy.  If it’s on the cover of JEMS, a Facebook page, or mentioned by the right “EMS celebrity,” we jump right in.  Whatever is the newest trend, we embrace it and go all out with it. Envision/AMR jumped into community paramedicine and spent like drunken sailors on shore leave.  AMR spent significant cash on critical care classes for paramedics, partnerships with hospital networks and hiring a significant number of “celebrity” EMS physicians.  Yet nobody ever asked the simple question, “Where is the money to pay for community paramedicine coming from?”  Apparently, nobody found an answer to that.  In other words, EMS spends money like the stereotype someone who just got a tax refund check — they put new flashy rims on a car that barely runs.  In all honesty, there’s not even a commonly accepted definition of what constitutes community paramedicine – primarily because community paramedicine programs are designed to meet unmet needs in the local community.  In other words, the needs of one community aren’t going to be the same as the next town over.  And in keeping with the free market principles of the US economy, if there’s money to be made meeting a need, it’s likely that a business will expand to fill that need. The fact that nobody was in the community paramedicine market should’ve been a big, giant, huge hint — there’s not much money to be made in diverting repeat users of EMS.

Second, like I’ve mentioned before, EMS is ill-informed and poorly engaged in the political process.  From the get-go, there was no guarantee that the Affordable Care Act would provide a revenue stream for community paramedicine, much less EMS as a whole. Next, with a Republican takeover of both houses of Congress in 2010, primarily as a response to the enactment of the Affordable Care Act.  The fact that Congress controls the purse strings of the Federal government should’ve been a hint to Envision/AMR that the Affordable Care Act was in jeopardy.  Yet, aside from seeing pictures of “EMS On The Hill Day” where everyone dresses up in an EMS uniform where they do their best impersonation of Idi Amin, I rarely see EMS involved in the political or regulatory at the Federal level and virtually never at the state level.  Healthcare is one of the most regulated business fields out there and to fail to engage, especially effectively, in the political and regulatory process is professional malpractice, if not out-and-out incompetence.  Say what you want about a certain large private EMS company based in Louisiana, but those Cajuns have a government affairs team and in-house legal counsel — and those Cajuns were smart enough not to nibble on the “reinventing healthcare” bait that the Affordable Care Act dangled in front of private EMS.  They’re also profitable and return the investment to their employee owners.  Jokes aside, that’s pretty impressive in any business, much less the EMS business.

Blaming President Trump for the possible sale of AMR is like blaming the dealer at a craps table in Vegas for the bad gambling decisions you made.  In conclusion, Envision took a huge gamble based on a poor understanding of the business and regulatory environment that it plays in.  And sadly, Envision’s employees are possibly going to be the ones who have to pay for the loss.

 

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.

Medicine and Politics

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

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

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

Are You Really Surprised?

This morning, I happened to read an article where a Senator was grandstanding about the supposed opiate abuse epidemic.  He was blaming the epidemic on everyone.  Doctors, the “evil” pharmaceutical industry, and even the DEA for not “doing something.”  Because whenever something is in the news, politicians want to “do something!”

I don’t deny that we have an epidemic of opiate abuse.  But at the most fundamental level, there is someone to blame — namely, politicians.  Our politicians have created government involvement in healthcare. (Whether that’s a good thing or a bad thing is another debate for another time.)  With government involvement comes the need to “measure” how effective the government interventions are.  And as we’ve all found when the government studies medicine, they like things that are easy to measure and sound good.   In EMS, that’s usually cardiac arrest survival — because dead or not dead is easy to measure and by golly, we don’t want dead people.

So, the government decided that “pain” was something worth measuring and studying for Medicare and Medicaid.  And then, the various accrediting bodies jumped on board because the government had already decided that pain management was a “good thing” and therefore measuring it for accreditation purposes was also a “good thing.” So, along came the messages.  Pain scale charts everywhere.  Providers being judged for pain management.  Providers being told that the goal is to get the pain to a zero on a zero to ten schedule.

But the reality kicks in.  In most acute settings (including EMS), we have limited pain management tools — mostly opiates.  And for the average person, pain is an emergency.  And I’ve already mentioned how hard it can be to get in to see a primary care provider and the inevitable referrals to specialists, labs, and imaging for all but the most minor complaints.  In short, if you’re in pain, you have two choices — be in pain until your doctor can see you and then get an opinion as to what’s wrong or seek immediate care and get opiates.

So, here we are.  People are rational and usually want relief now.  So, the tool of choice for acute pain management remains opiates. And people are now expecting their pain to be managed and they’ve almost come to expect that the relief will come in the form of an opiate. We’re now at the point where patients feel they have right to opiates for pain management.  Is it any wonder that we’ve created addicts?

And at the same time that CMS and the healthcare accreditation world demand that we “DO SOMETHING” about pain, the DEA and many state medical boards have differing opinions.  The current opiate “crisis” has led to a concern about overprescribing, which, in many cases, is rightfully justified. Especially in Texas, we’ve had a crisis with “pill mills” writing narcotic prescriptions way too easily for virtually no medical reason.  Those providers can and should be sanctioned.  But the DEA and the various state medical boards have also created a climate of fear where physicians feel as if their professional prerogative to treat patients is questioned, thus causing most chronic pain patients to be referred to pain management clinics, where again, there’s a wait to be seen, thus sending patients back to the acute care world and/or street drugs.

And as for the DEA, let’s not forget their unusual interpretations of the various controlled substances laws. Because most laws (including controlled substances laws) aren’t written to consider EMS, we’ve had some bizarre implementations of the laws by DEA in particular.  There are several DEA regional offices that have determined that EMS has no authority to administer any controlled substances (pain management and sedation).  Others have held that each ambulance and station (or posting location in system status management) has to be licensed as a facility by the DEA.  These competing interpretations have reached the point there’s legislation pending before Congress to clarify EMS providers’ authority to administer controlled substances.

And in the EMS setting, let’s not even discuss that the only pain management option we have in most systems is an opiate.  Opiates aren’t great for chronic pain or mild pain, but if the only tool you have is a hammer, everything starts to look like a nail.

I’ve been a lawyer in government practice for over twelve years now.  I don’t expect that you can get various government agencies to all get along or even use the same playbook.  But what I have come to expect is that if you get government involved in healthcare, you’re going to have some unintended consequences. The only thing you can consistently expect from government interfering in the physician (or nurse or medic) relationship with a patient is that there will be consequences.  And said consequences will be unexpected.  More often than not, they may even be worse than the problem they were addressing.

Time To Call It Like I See It

In my EMS career, I’ve been very fortunate for two things.  One, I’ve had the opportunity to work for some great EMS systems.  Two, by virtue of my outside career, I don’t have to rely on EMS to make ends meet or pay the bills.  To me, that also means I have an obligation to speak my mind about EMS, especially since many of my colleagues don’t always have the luxury of being able to speak theirs.

Today is one of those days where I’m going to speak my mind and say it as loud as I can. A few moments ago, I saw a social media post from a large EMS publication.  The post was entitled “Addressing Ten Harmful Realities of Modern EMS.” Plain and simple, I’m not going to link to it.  Here’s why.  To be honest with you, this article was written by an EMS consultant who’s been involved in the EMS world for years.  The article is published by a major EMS publication.

In short, we’ve got the same usual suspects of the same usual EMS columnists, the same usual people who are on every EMS committee, the same EMS publications, and the same EMS consultants telling how to fix the problems in EMS that, in large part, they’ve helped create and/or perpetuate.  At the very least, they’ve been complicit in not addressing them for a damned long time.

The main EMS publications aren’t peer reviewed.  They consist largely of reprinting advertisements for products.  The “science” they post is largely dated and the truly progressive EMS systems (the ones that aren’t busy tooting their own horns) have been ahead of the curve established by the EMS publications for a long time.  I can guarantee the pictures that’ll be shown in the same publications every month: namely a picture of fire-medics somewhere on the East Coast of the US, wearing full bunker gear, working a “scary looking” car wreck, and putting everyone on a backboard.  It’s at the point that several of my smarter friends have nicknamed one publication “Backboard Action” and refer to many EMS publications as “backboard porn.”  And mind you, the science has been trending away from the spinal motion restriction dogma for a while. Our EMS media isn’t the “conscience of EMS.”  It’s little more than a cheerleading section for the self-promoters of EMS.

The article goes on to talk about working conditions in EMS.  My friends, this article is written by an advocate for many of the practices that have created these working conditions.  If you like poor pay and system status management where you park your ambulance in an abandoned parking lot at 3:00 AM because that’s where the computer predicts coverage is needed, then, by all means, continue listening to the same people try to fix the problems that they’ve created.

The same people who’ve brought us these working conditions are the same people who continue to limit the knowledge base and educational standards of EMS.  Whether they use the “poor volunteers” or the fire service as their excuse, they continue to keep the same low standards and low expectations guaranteed to “meet minimal standards” and keep EMS down.  If you wonder why the best and brightest leave EMS for nursing or medicine and why the barely competent become EMS managers or educators, look right at the same EMS committee members who continue to pass on the chance to improve our educational standards or knowledge base.

And let’s talk about the medicine.  Let’s talk about the science.  That gets defined by our professional committee members and celebrity EMS medical directors.  Every year, there’s a “Gathering of the Eagles” where a bunch of celebrity EMS physicians present their opinions.  The Eagles, in theory, represent the fifty largest EMS systems in the country.  Large doesn’t equal great.  Far from it.  The District of Columbia, New York City, and Los Angeles aren’t exactly renowned for their quality of prehospital care. These presentations have a strong bias toward cardiac arrest.  While cardiac arrest is, in part, what EMS was started to fight, cardiac arrests represent a small portion of EMS responses.  Cardiac arrest gets studied because “dead” or “not dead” is easy to quantify.  Let’s talk about pain management.  Let’s talk about airways.  And let’s not dumb down the medicine because you have a large system of providers and it’s “too hard” to roll out training or keep quality assurance and quality improvement on “so many medics.”

A special mention to the majority of the EMS conferences as well. I’ve spoken at several, primarily state, conferences.  I’ve been fortunate in that these people are usually willing to let me speak my mind on a variety of topics, usually related to the law in EMS.  But the national conferences seem to represent many of the problems in EMS as well.  Namely, you’ve got “EMS celebrities” presenting topics that are either “fluff” or represent science that is already so well-established that it’s borderline negligence to not already incorporate it in your practice.  When speeches entitled “A Pressure Dressing For the Soul” or “Incorporating CPAP into Your Practice” are major speeches, the problem is clear.  By making everyone feel good about themselves and their practice of medicine, you may get “butts in the seats” but you’re sure not advancing the profession.  Just once, I’d pay good money to have someone present on the Dunning-Kruger effect and its applicability to EMS. Instead, we get feel good platitudes from someone dressed in a uniform that looks like a third world dictator.

In other words, the same people doing the same things in EMS aren’t going to fix it.  But I’m optimistic.  And here’s why.  New people in EMS are stepping up to the plate.  They’re recognizing the challenges in EMS.  And they’re advancing them, even when the usual gang of idiots tell them it’s pointless.  In 2014, two medics, who happen to be friends and inspirations to me, decided that EMS provider suicides were unacceptable.  They formed the Code Green Campaign.  Several other medics I know also decided to tackle mental health in EMS as well.  They formed Reviving Responders. And in 2015, when the Texas Legislature faced opposition from emergency nurses about allowing paramedics to function in the hospital, several Texas medics started talking on social media, shared the news, and formed the Association of Texas EMS Professionals to advocate for Texas EMS in the political arena.  The issue is not whether EMS can improve.  It clearly can.  It’s just time for us to recognize that what Mad Magazine calls “the usual gang of idiots” aren’t going to get us there.

To the younger EMS providers, I say, this is your time.  Stand up and lead EMS because the dinosaurs have failed to evolve and are doomed to extinction.  There is ZERO reason why EMS can’t become a respected medical profession entrusted to perform advanced assessments and interventions in the prehospital setting.  The only thing preventing this is that we’ve selected the wrong leaders.  Probably more accurately, we’ve been passive and allowed the wrong people to claim to speak for EMS.

Thank you for reading and for allowing me to be a voice out there.

You Get What You Pay For

In Texas, we have a strong tradition of limited government.  In particular, we limit the role of county government.  In most counties, county government provides law enforcement, jails, courts, and roads.  Because of the limits placed on county government by the Texas Constitution as well as the limited source of funds available to county government (primarily property tax revenues), the majority of county governments in Texas do not directly provide fire or EMS services.  In response to the need to fund fire and EMS services for smaller communities and/or unincorporated areas of the county, the Texas Legislature authorizes the creation of Emergency Services Districts (ESDs).   ESDs have the authority to levy a property tax to provide fire and/or EMS protection within their boundaries. That tax is up to ten cents per one hundred dollars of property value.

North Hays County ESD #1 is the Emergency Services District that serves Dripping Springs and much of the rest of northwestern Hays County.  They currently tax their property at a rate of 2.52 cents per one hundred dollars of property value.  They are holding an election on May 7 to raise the tax rate to a maximum of seven cents per hundred dollars of property value to continue funding EMS in their district.  Currently, San Marcos/Hays County EMS is their contracted EMS provider and, like many EMS systems, faces increasing call volume as well as increasing costs of providing EMS in the district.  (Disclosure: I formerly worked as a part-time medic for San Marcos/Hays County EMS. I have also responded with San Marcos/Hays County EMS on mutual aid with another EMS service in the area.)

Enter the local state representative in the area — a man named Jason Isaac. Mr. Isaac has come out publicly against the tax increase and is pandering to a reactionary anti-tax element of a conservative electorate.  Heck, I’m pretty conservative.  Those that know me have described me as a fiscal conservative, socially libertarian, and a neo-conservative hawk on foreign policy.  I’m no Bernie Sanders here.

If Mr. Isaac is truly concerned about the actions of the ESD, he would know that the Texas Department of Agriculture has information about the formation and operation of ESDs.  But it’s easier to put out posts on social media addressing an issue where the accountability lies with local government.  I thought that Texas conservatives favored local control and local solutions for local problems?

But there are some very legitimate roles for government to play, particularly local government. One expectation that all of us have, save for a few anarchists, is for our 911 calls to be answered and for help to come.  Better yet, we expect competent providers to deliver compassionate and clinically appropriate emergency medical care.  San Marcos/Hays County EMS has delivered that care to Hays County for years, including the residents of North Hays County ESD #1.  I’m standing for quality EMS, not sound-bites designed to appeal to fears about property taxes.

Think Nationally. Act Locally.

There are a lot of new ideas floating around EMS these days.  Compact licensure for EMTs and paramedics just like nurses already have.  Community paramedicine.  New educational standards.  And the list goes on.

Here’s why many of these well-intentioned ideas remain just that — well-intentioned ideas.  Many well-intentioned EMS opinion leaders with well-intentioned ideas have no idea how, or more importantly, where a well-intentioned EMS idea makes into law.

With a few notable exceptions (EMTALA, HIPAA, and CLIA coming to mind immediately), most EMS laws and regulations are creatures of state government.  Overall, emergency medical services are provided at the local level and are regulated by state statutes and administrative rules/regulations.

I see a lot of EMS folks wanting either Congress or some national body (e.g. National Association of State EMS Officials, the National Association of EMTs, or the National Registry of EMTs) to DO SOMETHING, DAMMIT!   I don’t always oppose their ideas (well, except for my healthy dose of skepticism about the so-called “Field EMS Bill.”), but they’re usually barking up the wrong tree.   If you want to make changes to the regulatory framework of EMS, you need to quit looking toward Washington.

As a valued service to my minions and other readers, I’ll tell you the way to fix EMS.  First, learn where your state’s EMS laws are located in statute.  Second, learn where the state administrative regulations regarding EMS can be found and which state agency or agencies create, implement, and enforce these regulations.  Next, learn who your state representative and senator are.  Also, learn who are the senior management in your state’s EMS regulatory entities.  And learn who are the chairs of the legislative committees overseeing EMS laws.

And then, when you want to change how we do EMS, contact those people.  Write, call, email, or better yet see them.  While the results may not be as sexy as going to Washington DC in a hotel doorman’s uniform and getting pictures posted online, the results will be more effective, easier, and might just improve EMS. One state at a time.

Core Maxims of EMS

Here are a few of my core observations and beliefs about EMS.

1) You can never go wrong catering to the lowest common denominator of EMS.  The success of Facebook groups like The Most Interesting Ambulance Crew In The World and t-shirts with themes including cutting clothes off of patients continues to prove this maxim.

2) Until EMS engages itself in political advocacy, our future and agenda will always be subject to the whims of others, whether it’s the nursing lobby, the fire service, or unelected bureaucrats in your state’s health and human services bureaucracy.

3) We’re always looking for the next BIG thing that will advance EMS.  Today’s flavor du jour is “community paramedicine.” As much as I like the idea, I’ve yet to see an easily defined skill set or a knowledge base that’s portable across jurisdictions.

4) As long as we continue to define ourselves by a skill set (e.g. I’m a paramedic, therefore I intubate), we will, at best, remain a vocation.  Honestly, right now, we’re a collection of skills more or less randomly put together as “things that might be useful to know in a medical emergency.”  (Otherwise, how could some universities offer a 2 week program for nurses and physicians to become paramedics?)

5) What passes for our education prepares us for emergency medicine.  What our call volumes is typically represents urgent and primary care with a few actual emergencies on occasion.

6) There’s a joke about leaving two firefighters in a room with a ball bearing and that it would be broken in an hour.  Leave two medics in a room for an hour and there will be a clique of “cool kids” and a rumor mill be going.

7) Patients don’t know how good your medical skills or knowledge are.  They are more than capable of figuring out whether or not you actually care for them.

8) If you’ve seen one EMS system, you’ve seen one EMS system.  At least in the USA, there’s no one ideal model of EMS system or service delivery.  What’s going to work in Presidio, Texas sure isn’t going to work in downtown Seattle.

9) Any EMS service that constantly bangs the PR drum to tell you how progressive they are probably isn’t all that progressive.

10) There are a few EMS systems out there that aren’t worth keeping.  Start over from scratch.  Washington DC. Cough. Washington DC. Cough.

11) The current EMS educational models and examination models give a de facto veto to whichever state has the lowest standards.

12) The most overlooked aspect of an EMS student’s educational experience is their set of clinical rotations.

13) Pain management matters.  Having said that, EMS providers need a non-narcotic option as well.

14) As long as people are willing to accept substandard working conditions, substandard working conditions will exist.  In other words, if you don’t like parking on a street corner for 12+ hours, don’t work there.

15) You cannot build an EMS system without taking care of your medics.  Period.

16) In the overwhelming majority of cases, communities get the EMS system they pay for. A suburban bedroom community that chooses to only have a BLS volunteer service shouldn’t act surprised when a crew isn’t available at 3:00 PM.

17) Until the average EMS provider can use, pronounce, and spell medical terminology with something approximating intelligible English, we shouldn’t be surprised when our healthcare colleagues seem hesitant to trust us with high-risk procedures like intubation and surgical airways.

18) The follow-on to #17 is that we need to prove ourselves competent with our current skill-set in emergency medicine before we can legitimately expect to be entrusted with the expanded scope of practice in community paramedicine or critical care.

19) We’re fooling ourselves when we have providers who want EMS to be able to refuse to treat or transport “low acuity” patients while at the same time parroting the phrase, “We don’t diagnose.”

20) If we truly have a national EMS exam and a common educational standard, reciprocity across state lines should be a virtual given.  Artificial barriers and hurdles established by state licensing entities represent one of the banes of EMS — turf protection.

Final one….

21) Turf protection wars (fire versus other delivery models, private versus public, BLS versus ALS, ad nauseum) will end up proving Ben Franklin’s adage about hanging together rather than hanging separately.

 

An Open Letter to the EMS Media

Ambulance Chaser here.  Overall, I’m a huge fan of EMS media, both online and print, and making EMS information available online to our fellow professionals.  However, I’ve noticed a disturbing trend in several of the EMS websites and publication.  The articles related to law and EMS legal issues tend towards sensationalism, inducing panic and fear amongst providers, click-bait, or stirring up business for the attorney writing the article.  Articles on liability tend to report on isolated, extreme cases out of trial court verdicts or settlements, which do not create binding law anywhere.  And more than one article has ended with information about how to contact the attorney-author for more solutions to the problem they happen to be writing about.  And we know that HIPAA and privacy issues are routinely invoked as bogeymen waiting to trap unsuspecting EMS providers, when we all know that realistic common-sense measures address most compliance issues.  But that doesn’t drive up “clicks” on the website nor clients to the lawyers to purchase a tailor-made compliance handbook and checklist.

And let’s not even talk about the constantly invoked specter of losing your license, getting sued, or gasp, going to jail.  Yes, EMS provider liability exists.  (Honestly, in my opinion, I think more providers should be sued for some of their acts.)  But the liability for EMS providers and EMS systems is a creature of state law in the overwhelming majority of cases.  Continually citing an attorney who practices in one of the worst possible states for tort liability is at best, fear mongering, and at worst, disingenuous.  It’s as self-interested as for a CPAP vendor to write an article on how and when to use CPAP.  Heck, most of the publications put that kind of obvious infomercial in a “special supplement” to the magazine.

And heck, we’re ignoring several of the big issues in the legal arena that continually “bite” EMS — wage and hour claims, employment discrimination claims, tort liability for vehicle operations, and compliance with state administrative regulations.  But of course, it’s much “sexier” to write about some case where some medic in West Cornfield got sued because of a bad outcome for the patient.  Posting an article like that, of course, brings out the legal experts who populate Facebook and social media.  And that drives up the clicks on the website.

For EMS to progress, we are going to have to develop our own core of “experts” in fields related to EMS, including law, politics, and policy.  At the risk of sounding exceedingly self-interested, I believe I fit into that role.  I am one of the few attorneys who’s actively practicing both law and paramedicine.  I bring a focus on addressing and managing risk to legal issues, including those in EMS.  Additionally, with much of my career being in state government, I have a real understanding of the political, regulatory, and advocacy processes that many in EMS do not possess. (If you’ve read my blog in the past, you know my thoughts on what’s right and wrong on our efforts at advocacy and politics.)

I’m not asking for a column or a position (although I’d certainly be open to it).  What I would respectfully request as an reader as well as a practicing EMS provider is that we demand the same excellence in media addressing EMS legal issues as we would clinical issues.

Sorry for what seems like a more self-interested post than usual, but, to a large extent, what the EMS media is publishing as legal education is just not what most providers need.