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.

EMS Week Resolution

So, it’s EMS Week.  Hopefully, by now, you’ve gotten your free cafeteria meal and/or slices of Little Caesar’s pizza from your local hospital, assuming the nurses didn’t eat it before you got there.  You might’ve even gotten a t-shirt or some other motivational knickknack. It probably has some inspirational saying and lots of Stars of Life festooned all over it. After all, you’re a lifesaver.  You race the reaper.  You’re special, dammit!

Ok, time for us to take a minute and grow up.  I mean, for real.  Last night, I got involved in an online discussion about EMS providers in an unnamed state (let’s call it the Keystone State, for the sake of this discussion) being required to retake the National Registry if they were even a half hour short on continuing education.

Gasp.  Horror.  OHMYGOD — ZOMBIE APOCALYPSE!  How dare these people be held accountable?  We’re always saying EMS doesn’t get trust or respect from the rest of the healthcare and public safety world.  Why?  Because we don’t want accountability.  Whether or not you like the rule, it’s there.  And if you’re a professional, you have to take responsibility for maintaining your certification.  And yes, that includes taking the initiative to maintain and keep up your continuing education hours.  No one else, other than you, has that obligation to yourself.  In other words, if you want to maintain the ability to feed yourself as an EMT or a paramedic, you’ve gotta get the CE hours.  No way around it.

So, when everyone finally realizes that’s part of the deal to being a medic, then the argument comes out that no other healthcare providers have to take the licensing exam again if they don’t have their CE hours.  Whose fault is that?  It’s ours.

But how is it our fault?  Quite simply, we’ve given up (and probably never had) any semblance of being interested in or capable of self-regulation.  How many EMS people know how their state’s EMS legal and regulatory framework is set up?  Know where to find your state EMS Act?  Know where to find the physician licensing statutes?  (Because that’s probably got the information about what and how a physician can delegate practice to EMS providers.)  Know where your state’s EMS administrative rules are?

Ok, do you know how these things are created?  Can you describe how a bill becomes a law in your state legislature?  Can you describe how an administrative rule or regulation is adopted in your state?  Know what a public comment period is?  Know how to file a public comment?

If you don’t know, or worse yet, if you don’t care — you are why EMS is held back.  I will guarantee you that part of why nurses have the power in the healthcare world is because nurses are organized.  They fight like hell to maintain their own professional regulation.  They have state nursing associations to fight at the state capitol and to tangle with bureaucrats and regulators.  And as such, they, along with physicians, dentists, and even lawyers have their own professional regulatory boards.  And these boards, wait for it — they’re largely made up of the professionals that they’re licensing and regulating.  Us?  Most states don’t have an EMS regulatory board.  We’re slammed into the state health and human services bureaucracy right there with the tanning salons, tattoo parlors, and giving immunizations and running mental hospitals.  No wonder we’re neglected.

It’s a lot more fun to bash lawyers.  But good administrative lawyers who can deal with the regulatory machine and lobbyists who know the state legislative process are what EMS needs to advance.  Where’s EMS at the state capitol?  Not present, except for maybe a congratulatory resolution during EMS Week.  It’s the political version of Miss Congeniality or “everyone gets a trophy.”

Meanwhile, our national EMS association that claims to be the voice of EMS continues to tilt at windmills at the Federal level and think that passing the so-called Field EMS Bill and its grant funding mechanism will fix EMS.  Nope.  Not hardly.

What will fix EMS is when we grow up, demand self-regulation as profession, and grow the political skills to make it happen — and then keep it.

Let’s make EMS Week 2014 the point at which EMS grows up and becomes a profession.  But first, grab that last slice of Canadian bacon and olive pizza before Tina from Radiology gets it.

Is EMS about to keep itself irrelevant?

With much ballyhoo and publicity, we’ve heard a ton about increasing educational requirements for EMS.  The National Registry now requires a paramedic candidate to have graduated from an accredited paramedic program.   What does accreditation mean?  Speaking cynically, it means that an education program has gone through a process where it has created a big ol’ (Yep, “big ol'” is a Texas colloquialism, so deal with it…) policies and procedures process that may or may not have anything to do with academics and/or successfully creating baby paramedics.

And at least some of the EMS world is clamoring for a degree requirement for paramedics.  They’re convinced that a degree for paramedicine will enhance both pay and professionalism.  They point to nursing as an example where this has happened. Perhaps.  Maybe.  Respiratory therapy now has degree programs and, if I remember correctly, its pay hasn’t skyrocketed like nursing.  Correct me if I’m wrong.

What concerns me about the EMS education trend is this.  We are continuing to look at an EMS degree as a technical thing.  More hours in the hospital.  More hours in the classroom learning what paramedics already know how to do.

What EMS hasn’t done is grow a future generation of EMS leaders and thinkers.  We need paramedics who know public health, public policy, management, the political and regulatory processes, and dare I say it, the legal realm. EMS is a business, whether it’s publicly run or a private enterprise.  Johnny and Roy may know how to intubate, but if Johnny and Roy can’t make a budget, deal with HR, and deal with Capitol Hill, Johnny and Roy are going to remain the bastard stepchildren of healthcare.

If we’re going to have a debate about a paramedicine degree, let’s be sure that we know what a paramedicine degree should contain.  And let’s start growing a cadre and a core of EMS subject matter experts in all of the fields that touch EMS — not just experts in EMS.

Be the change. Infiltrate.

So many people have complained about the lowest common denominator (or “low information voter” AKA LIV) tendencies in EMS and EMS management (both clinically and operationally) ad nauseum. What we haven’t done is begun to fix it. The path is deceptively simple. Infiltrate. Infiltrate. Infiltrate. There are tons of committees, focus groups, etc. out there. Imagine if each of these committees had a strong advocate for higher EMS standards on them advocating for change or at least showing the way.

Currently, I’m up at NREMT helping review EMT exam questions. Watching a medic’s eyes pop out at reading a sepsis protocol that involves more than fluid resuscitation has been worth the trip alone.  I don’t blame him.  I blame his regional system for maintaining a lowest common denominator EMS system.  I blame the fire departments and private services that want a lowest common denominator system for the express purposes of lower wages and/or ease of training.

Get involved. Infiltrate. Be the Fifth Column that corrodes the lowest common denominator mentalities from the inside. If nothing else, it adds to your personal contact list.  And just maybe if we have the advocates for high quality EMS networking with each other, high quality EMS becomes the denominator.

Endangered Species

So, I recently read an article online in Fire Apparatus Magazine bemoaning the state of EMS. Because, as we all know, the most current information on emergency medicine comes from a magazine that shows pictures of big red shiny trucks.

When you go through the article (I’m not going to link it because I don’t want to give this guy any more legitimacy), he raises the standard argument that fire chiefs and large EMS system managers always use as their stalking horse in their arguments to keep EMS educational standards low — or even lower them. Yep, that’s right. The mythical rural EMS volunteer who will disappear if we change the science and/or add one more bit of knowledge to their already overflowing brain.

I feel more than qualified to address this issue. I’ve spent the majority of my EMS career as a volunteer at both the EMT and paramedic levels with both fire-based systems and third service models. I’ve worked urban, suburban, and rural. The majority of my experience has been in combination departments where paid and volunteer medics work side-by-side. And to the premise of this article, I say, “BULL.” Well, I said more, but this is a family-friendly blog.

I’m more than tired of using the overworked rural volunteer provider as a straw man. First, regardless of whether you draw a paycheck or not, an EMT or paramedic certification is the same. In many states, you can’t say the same for a paid versus unpaid firefighter. Second, in my experience, volunteers are some of the most motivated people out there when it comes to seeking continuing education and opportunities to advance their medicine. In the rural service where I currently volunteer, we have an active continuing education program consisting of monthly online classes as well as a full panoply of “card courses” covering resuscitation, cardiac care, medicine, trauma, pediatrics, and tactical medicine. Our medics, at all levels, routinely exceed state mandated training requirements. I’d further note that several of our paramedics are volunteers who work in outside professions and maintain licensure in those professions as well. Furthermore, come to any of the big EMS conferences. There, you’ll notice a disproportionate number of volunteer providers, especially compared to those employed in large EMS systems.

In short, Chief Haddon of the North Fork, Idaho Fire Department is wrong. Volunteer EMS providers can, will, and do exceed educational requirements and expectations. Give them a chance and you’ll find out. And if you don’t believe me, I’m extending a personal invitation to come down to Texas. I’d be happy to introduce you to some volunteers who actively seek to improve themselves professionally for the benefit of their patient. Heck, I’ll even treat to BBQ.

I’m not expecting a visit, though. It’s a lot easier to use the myth of the overworked, overwhelmed volunteer EMS provider who will go away if we add one more class. Sadly, this “don’t need to know it mentality” usually only benefits the “mongo mentality” of “you call, we haul” that seems to hold back EMS. The worst part is that the same departments and administrators who bemoan increased EMS education can be seen at all of the structural fire conferences. Maybe its time to have more volunteer EMS systems and less volunteer fire systems?

Big Mac or Porterhouse

I’ve noticed two interesting discussions going on simultaneously on EMS social media.  One discussion, which started on the National EMS Management Association list on Google Groups initially started out as a medical director trying to update his protocols.  It has since evolved (or perhaps, devolved) into a discussion about keeping endotracheal intubation as a paramedic skill.   The usual positions are being hashed out.  Again.  In short — one position is that EMS, as a whole, doesn’t do a good job at intubation — either in initial education and skills mastery or in skills retention.  The other side is the argument of “That may well be true, but things are different at the XYZ EMS System where we absolutely excel at intubation.  Here’s why and take a look at our numbers.”

Another discussion has been brought up by friend and fellow blogger Chris Kaiser.  He’s raised some very good concerns about the current American Heart Association Advanced Cardiac Life Support program sinking to the level of a merit badge course that every advanced life support EMS provider has and that most hospital staff have.

I see both of these discussions as a symptom of what I call the McDonald-ization of EMS.  In other words, we want to ensure a similar experience wherever you get EMS, regardless of previous excellence (or incompetence).  Face it, when we travel, we stop at Mickey D’s because we know what we’re getting, not because it’s the best burger anywhere.

EMS seems to be trending towards this as well.  The statistical gurus and the usual crowd of professional committee members and buzzword repeaters all bloviate (sorry for the Bill O’Reilly word there) about the need to have a common standard.  Two problems there.  First, the common standard doesn’t take into account the variations throughout the entire United States.  To me, it’s unreasonable and illogical to presume that Cut Bank, Montana and Boston, Massachusetts have the same needs for EMS, much less the same populations and sources of funding.  Second, like McDonald’s, when your chief concern is consistency, your product or service easily becomes the lowest common denominator.  What you end up with is a consensus model where pit crew CPR, good airway management (both including and excluding intubation), and even more cutting edge advances like dual defibrillation and transporting certain cardiac arrest patients straight to the cath lab end up sacrificed because “we all need to be delivering the same care everywhere.”

As for me, I’ll take the occasionally singed porterhouse in recognition that even that is better than the uniformly average Big Mac, which for the record, isn’t even prepared the way I like my burgers to begin with.  It’s time that we quit punishing the EMS services that try to deliver excellent patient care just so that everyone receives the same, consistent, AVERAGE care.

Of course, the statistician will tell me that there’s always going to be an average.  We just need to keep IMPROVING what we do so that the average keeps advancing too.

Two quick observations….

About EMS legal/political issues.

1) Most EMS legal issues aren’t actually analyzed by an attorney.  Rather, they’re analyzed by a person with no legal training who is making an exceptionally uneducated guess about what they think a lawyer might tell them.  You know, it’d be like the random attorney reading a 12-lead with no education.

2) People seem to think that if a definition in the law is changed to make EMS an “essential, ” “emergency, ” or some other word attached to service, then the “powers that be” will HAVE to fund EMS.  Anytime anyone says that a definitional change to the law will ensure EMS funding, it’s obvious that they don’t understand law, politics, public policy, economics, or the political process.  If you believe a change in law will fund EMS, look at the amount of lawsuits over the equity (actually, the amount) of public school funding.  This kind of simplistic thinking shows why EMS still isn’t invited to the “big kids’ table.”  And EMS’s simplistic fascination with the next big funding bill is shown in the mindless support of the so-called “Field EMS Bill” that NAEMT hawks as a snake-oil panacea to every EMS problem.  After all, we all know that endless streams of Federal money fixes every problem.