What does the patient/client want?

I’m trying to put some complex and jumbled thoughts into words here, so bear with me. As some of you may know, I’ve dealt a ton with health issues for various family members over the years, especially over the last few months. One thing that I’ve seemed to notice is that too many people in healthcare think they’re helping when they’re substituting their own wishes and priorities for that of the patient and their loved ones. Further, many professionals in both medicine and law forget that the patient/client and their families have a life outside of and in addition to the matter currently being addressed. The outside world rarely pauses and often refuses to pause so that a patient/client or their family can reschedule the outside world at a moment’s notice all because someone feels that their little niche or agenda has to be addressed right this minute.

As a result, the patient and their family feel that the providers of all kinds, whether physician, nurse, therapist, or case manager, are dictating to them rather than caring for them. It can easily make the patient and family feel as if they have no control over matters relating to their care. Example: “You have to be here for a very meeting. Today.” Reality: Here’s the same discharge plan that we’ve been discussing for several weeks. 
 
People often feel an absolute loss of control of their care and their wishes. And when people feel they’ve lost control of their own affairs and that their wishes aren’t being heard, they’ll find another way to ensure they’re heard, whether in court or in filing a complaint with a regulatory agency. The nature of our healthcare and legal systems being what it is, the courtroom or administrative complaint is the only way that some clients/patients and their families feel that they will be heard.  (Free legal advice: it takes a lot less time and money to be nice up front and explain things early than it does to answer a lawsuit or an administrative complaint.)
 
Part of being a professional is in recognizing that the patient/client still maintains autonomy – the right to make their own decisions. Your job is, within the confines of the law and ethics, to help that patient meet their stated needs and goals. Being a professional means giving a patient/client the services and all of the information they need to make a good decision, then abiding by that decision and putting the patient/client first.  Heck, even as a lawyer, clients go against advice all of the time. Look how many criminal defendants insist on testifying in their own defense.  Look how many DWI suspects agree to take field sobriety tests and take the breathalyzer, even though they’re basically giving the evidence to convict themselves.  As I like to remind professionals of all sorts, people have the right to make bad decisions.  Fundamentally though, as a professional, we exist to provide services to our patients/clients in accordance with their wishes. 
 
This should ring true whether it’s medicine or law. And it’s a good prescription for limiting your involvement with lawyers to represent you. As another EMS colleague of mine says, “We can suggest, but forcing patients to do what they don’t want buys lawyers nice cars.”

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

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

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

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

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

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

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

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

 

How To Create a Paid Fire/EMS Department

As of late, I’ve posted a fair amount about the local politics involved with the various tax-funded emergency services districts in my part of Texas basically ending volunteer participation. Truth be told, I definitely think there’s some shenanigans from paid staff and their union locals. But folks, if we’re going to talk about the end of volunteer participation, we need to take a long hard look at the volunteer culture.

As I often teach through sarcasm, I present the following recommendations for ways to ensure that your volunteer department becomes a combination department and eventually a completely paid department.

  1. Run the department as your own private social club.  By gosh, this is a place for the connected locals to hang out, use as a private lounge, and maybe go travel on someone else’s dime.
  2. Training?  Why do it?  And if you do feel you have to do it, focus on cool, fun stuff instead of the basics of being able to operate at a fire, rescue, or medical call.
  3. Membership? Who needs that?  If people want to join us, they’ll find us. And if they do figure out how to join the department, ensure that the process is all about who you know rather than what you’ll bring to the department. And if you do a membership drive, make it a joke.  Either try to recruit “heroes” (as opposed to members who want to help others) or do the same tired routine that you do every so often and then claim “nothing’s working.”
  4. Speaking of what you bring to the department, always make sure to turn down free help. If the person can’t make the arbitrary number of meetings or responses, or lives “too far,” don’t show any flexibility.  If you’re a combination fire and EMS organization, be sure to turn down someone only interested in one discipline. It’s not like having an extra medic frees up a firefighter or vice versa.
  5. Accountability and transparency is for the birds.  You’re heroes!  There’s no need to justify your budget or be accountable to those politicians at the county or the city who “don’t understand what we do.”
  6. Speaking of budgets, let’s be sure to spend like drunken sailors on shore leave. Buy those big-ticket, rarely used capital expenditures regularly, then run around scavenging for IV needles and working radios.
  7. Responses?  We’re volunteers.  We don’t have to go to a call if we don’t want to.  And we sure don’t go to “old so-and-so’s” house or the local nursing home.  It’s not like they really need help. And especially if you have paid staff working with the volunteers, there’s no need to go to all calls, only the fun ones.  And if you show up on the fun calls and don’t get to do “fun” stuff, by all means, complain loudly.
  8. Uniforms?  They need to fall into one of two extremes.  Either no uniforms and look like “People of Wal-Mart” or uniforms that make you look like an Italian Field Marshal.  No need for things like photo ID cards, t-shirts, polo shirts, and jackets.  It’s either the Redneck Yacht Club or the full parade dress.
  9. Be sure to remind new members that they don’t know how “we do things around here.”  Be especially unwelcoming to experienced people who have significant prior experience.  It’s not like they bring anything to the table.
  10. Don’t create strong relationships with the other members of the public safety team.  No need to play well with the surrounding fire or EMS agencies, much less law enforcement.  It’s not like you’ll ever need any of these guys again.
  11. And if you have a state organization for volunteer fire and EMS, don’t join it.  And if you do end up joining said organization, ensure that your organization is quiet at the state capitol.  We don’t want to antagonize the paid guys or advocate for volunteers.

So, if you follow my  program, what will you get?  Simple.  Eventually, the taxing entity and taxpayers will tire of your antics. They will point to your lack of training, transparency, fiscal responsibility, and shrinking membership roster.  First, they’ll bring on a small duty crew during the day to “supplement” the volunteer staffing.  Eventually, that supplement supplants the volunteers.  And somewhere during this process, your department becomes absorbed by the taxing entity.  Congratulations! Your non-profit volunteer group has now become a fully paid local government department.  But of course, the fun only begins.  All of the time and effort that you could’ve spent on having a functional volunteer or combination department can now be spent on lengthy political and legal battles over who gets the property from your department.

This story repeats itself over and over again, yet we don’t seem to learn.  The average volunteer emergency services provider is often their own worst enemy and the biggest reason why departments go “professional.”

And so it goes.

Cleared To Practice, AKA: The License To Kill

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

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

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

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

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

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

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

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

EMS is OUR Profession

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

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

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

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

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

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

Thoughts From The Sidelines

After EMS Today last week and dealing with some family medical issues, I have a few thoughts to consider.

  1. EMS is the practice of medicine.  It always has been and always will.  As such, we owe it to our profession and our patients to focus not only what’s cool, trendy, and “sexy,” but that which benefits our patients.  Unless you’re really working in the appropriate setting, put down the Tactical Medicine book and pick up something to learn about lab values, airway management, or sepsis.  Your patients will benefit.
  2. EMS systems used to advertise that EMS is  “more than just a ride to the hospital.”  It’s time to remember that and start treating patients early in the field, if they will benefit from or need that treatment.  The idea of “we’re just five minutes from the ER” is malarkey  (I initially put something stronger in here, by the way).  Except in patients near death, it’s going to be a bit before the emergency department begins treatment.  Things like fluids (where appropriate) and pain management are often quite a ways down the road, even when the ER is five minutes down the road.  Treat your patient.
  3. The old saying “It’s not my emergency” remains true.  But an old piece of advice that I got from a San Marcos police officer still applies.  “To the person who called 911, this is the most important thing that’s happened to them today.”  Respect that as well.
  4. If you’re burnt out, step away.  Whether it’s cutting down on overtime, taking a vacation, or finding a different way to rejuvenate yourself, being burnt out doesn’t serve yourself, your patients, or our profession.

It’s a hell of an honor for the public to trust us to walk into their most private spaces at their most vulnerable moments and trust us to care for them.  Too many of us have forgotten the public trust and care aspects of our profession.  If you have to ask if this applies to you, well, maybe it just does.

Couple of Quick Thoughts

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

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

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

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

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

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

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

It’s Not EMS Abuse; It’s EMS Use

There’s a lot of talk about “EMS abuse” by EMS providers. I’d submit there’s a lot of EMS “use.” We’ve done a good job of telling people to call 911, but we’ve failed in telling them what an emergency is, what EMS is, and what EMS can do for them.

From the days of William Shatner and his overly dramatic voice, we were told to call Nine One One. The public has an idea, that we’ve promoted, that if you call, a group of well trained professionals will show up and fix any problem at any hour. Truth be told, that’s not too far off.  With the possible exception of 24 hour plumbing and some food delivery options, we are about the only people doing that who are actually available 24/7.  And unlike those others, we don’t expect payment at the time of service.

Until we have better alternatives, involving EMS, primary care, and the public safety net, we’re going to continue to have EMS “use.” How many of us have spent the time actually educating the public about who we are and what we do?

In addition to my EMS career, I’m also an attorney. I find it amazing how many educated people have virtually no idea of what EMS does or how it works, aside from help coming if you call 911. I regularly run into professionals in other fields, even including the medical field, who don’t know the difference between an EMT and a paramedic.  We’ve done a terrible job of promoting EMS and explaining who we are and what we do.  The idea of EMS “abuse” is a direct result of our success in telling the public to “call 911 for an emergency.”  And the rest of the medical community uses us to punt to.  Call a physician after hours and their recorded message is likely to say, “If you’re having an emergency, hang up and call 911.” The challenge is that EMS and the public most likely define “emergency” differently.

Back when I was in third grade in Austin, we had a week in school called “Be A Medic Week.”  We learned some basic first aid concepts, how to call 911, and got a tour of the ambulance.  (FYI, back in the early 1980s, some of the ambulances here were still low top vans.) We need to be doing the same sort of education with the public as a whole.

It’s time to show our ambulance to the public and introduce ourselves.  This is what EMS Week should be about — not seeing which ER is providing us with free pizza. (Besides, the good pizza was already eaten by day shift or the respiratory therapists.) Let’s do some actual community outreach, promote ourselves and our profession, and educate the public and even the other healthcare professionals. Who knows?   Maybe it might lead to some increased recognition, better understanding of who we are, and maybe even some increased confidence in EMS.  Maybe even some increased pay eventually.

Right now, there are too many people who think that ambulance driver, EMT, and paramedic are interchangeable terms.  What are you doing to fix that? Fix that and it’s quite likely that current EMS “use” will correct itself.  I’m tired of people being afraid or unwilling to call us for their actual emergencies because they didn’t think we could help.

Lets have that conversation with the public about who we are, what we do, what’s on the ambulance, and how we’re trained. People should know that their EMS system, particularly if it’s staffed at the paramedic level, is often capable of providing the same care as you’d initially receive in the emergency department, will get you to the right emergency department for your condition, and have the ability to consult with a physician if needed.  Texas regulations refer to a paramedic equipped and staffed ambulance as a “mobile intensive care unit.” That’s a very appropriate description for the two systems where I’m fortunate to work. We have the training, equipment, and medications to provide assessment and care that approaches emergency department and ICU care.  I’m even more fortunate to work with colleagues who recognize that it’s a privilege and public trust to be able to walk into your home or business to care for you or your loved ones.

It’s a conversation that’s long overdue and one that I’d be proud to have with any of you.

Seriously, if you have questions about EMS, ask one of us.  And if you even think you’re having an emergency, call us.

A Couple Of Reviews

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

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

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

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

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

All Politics Is Local: Or an EMS Labor Union and the Kerfuffle

There’s been a lot of discussion on EMS social media about the contract between the City of Austin and the Austin/Travis County EMS Employees’ Association (AKA: The Union) lapsing. I’m not a medic for ATCEMS, but I feel compelled to wade in as an Austin resident, a paramedic, a public sector employee, a friend of many of the medics in the system, and as someone who was a first responder within the system. I’m going to give this my best effort and will probably not gain any friends as a result. But that’s ok – as the old joke goes – lawyers have feelings.  Allegedly.

This is a system that’s had issues for a while. And this isn’t solely a greedy public employees’ union issue.  Nor is it an issue of terrible management. The truth be told, it’s a horrendous combination of lousy union leadership and equally inept city leadership.  The union leadership has sold its membership one scheme after another as the “one big fix” to the challenges of working in EMS.  I remember several years ago when there was entirely different leadership at the union, EMS management, and even city management.  A paramedic ran for the union presidency on a promise of replacing the current (at that time) 56 hour work week of 24 hours on and 48 hours off with a guaranteed 48 hour work week – for the same pay.  Needless to say, neither EMS nor city management were enamored with the idea of cutting hours for the same pay.  Then the union president raised the issue of “safety.”  That’s an issue that, once raised, can’t be recalled. At that point, the city hired a consulting firm to examine EMS scheduling and the determination was made that many of the stations were too busy to be on 24 hour schedules.  To this date, scheduling and station assignments remain one of the biggest challenges at ATCEMS. A variety of schedules have been tried and active fatigue management policies are now in place.  While the fatigue management policies are welcome and needed (especially after the death of a respected ATCEMS captain who fell asleep while driving), the reality is that all of the scheduling fixes fail to address the underlying problem – a busy EMS system that does not have sufficient staffing or crews, especially in the areas of highest call volume in the center of the city.

The call volume in central Austin also impacts other parts of the system.  Many of the ambulances from the other parts of Austin have to transport to hospitals in central/downtown Austin.  Once those trucks become available as they leave the hospital, they are assigned calls in central/downtown Austin.  The crews call this “getting sucked into the vortex.” Meanwhile, the more outlying areas of the city are without their ambulance – all because no one recognizes the 800 pound gorilla in the room – the central part of Austin with its socioeconomic demographics, the entertainment district in downtown, and two homeless shelters less than two blocks from the entertainment district.  The solution was, is, and remains additional EMS resources in central/downtown Austin.  No other solution is a solution.

And let’s talk about the outlying areas some. Pretty much since the EMS system was created in Austin, Austin has supplied paramedic-level transport for all of Travis County.  Each of the fire departments in Travis County (including Austin FD) have provided first responder services under the protocols and medical direction of ATCEMS. In THEORY, ATCEMS protocols allow for the “credentialing” of these fire departments’ advanced/intermediate EMTs and paramedics to function at their state certification level. The reality is that the credentialing process is very similar (and probably rightfully so) to the field training process that ATCEMS medics go through to be “credentialed” for independent practice.  In actuality, the process exists largely on paper. The process is too long and involved for many departments to commit an employee for this extended period.  And it serves ATCEMS to limit the number of providers above the EMT level.  As a result of this process, its lack of transparency and clear standards, and the underlying motives in limiting the number of advanced providers, ATCEMS has alienated many of the fire departments in the county.  Pflugerville was alienated to the point of creating its own fire-based EMS system and completely separating from ATCEMS.  Two other departments have their own medical direction now for paramedic-level first response.  This failure reflects right back on both ATCEMS leadership and ATCEMS union leadership.  In fact, one union president told Pflugerville that his job was to protect his members. Granted, it’s probably the truth, but at least be politic enough to couch it in terms of patient safety, patient care, and patient outcomes.

If management deals in good faith with employees, there’s little hue and cry for a union, much less civil service protections. Witness the number of Japanese auto plants in the US where workers have actively rejected unionization attempts by the United Auto Workers.  ATCEMS has had a history of employee discontent and morale issues.  I know paramedics from the early 1990s who complained about being assigned to a mandatory overtime shift at the busiest station in the system (and one of the busiest in the US) right after working that same station for the previous 24 hours. As the morale problems continued and several provider suicides occurred, Austin’s previous medical director was replaced by a new medical director who came in from the outside.  One of his first of many arrogant moves was to push for ATCEMS to hire EMTs because he believed that there are too many paramedics in EMS and he didn’t believe there was evidence to support advanced life support providers.  This mindset was that of a physician who seemed to define EMS success by cardiac arrest statistics alone. A new “Medic I” position was created where anyone with an EMT certification or higher would be eligible to apply.  After a period of 1-2 years as a “Medic I,” those with a paramedic certification would be eligible to promote to the “Medic II” position as a paramedic-level provider. Needless to say, this change increased the workload on system-credentialed paramedic providers and also turned off many experienced providers from applying to work for ATCEMS.

While ATCEMS has since replaced the medical director with a much more progressive and aggressive medical director from the Houston area, the Medic I/Medic II model is now virtually codified as a result of ATCEMS moving to civil service. As a result of the continued workplace discontent, the latest “solution” from the union was “civil service.” Civil service would provide for state laws (or a negotiated contract with the city) to govern employee relations including hiring, promotions, and discipline. It has also codified a management team and culture where, other than the department director and medical director, all promotions are from within the department.  And this is a department that is so insular that it still believes its own PR machine about how progressive it is.  In fact, until the mid 2000s, the ATCEMS patch still had “System of the Year 1985” on it.  While other EMS systems have added paralytics for intubation and multiple other drugs and interventions, the bureaucratic inertia of ATCEMS has turned the previous clinical excellence into just another large urban EMS system, albeit without the requirement to become a firefighter. And just like most fire departments where the IAFF rules the roost, the union was created as a result of management strife, but requires on continued strife to justify “this is why we need a union.”

And now the employees are without a contract.  And “this is why we need a union.”  And so it goes.