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.

The Challenge of EMS Conferences

I attended EMS World Expo last week in Las Vegas and had a good time.  I had the opportunity to reconnect with several of my good friends in the Las Vegas emergency medicine world.  I got to see a bunch of people who I only see at these conferences and meet several people who I previously only knew through the Internet. And I ate like a king.  (If you know me away from the blog, you can easily find my Yelp reviews with some incredible food suggestions for Sin City.)  And being as it was Vegas, well, I had fun in Vegas.

But here’s the sad, but honest truth.  I learned very little.  I did come away with one huge new thing — apparently, there’s now an EZ-IO placement in the distal femur for pediatric patients.  But the rest of the presentations were pretty “ok.”  There’s not a lot of new information out there.  And sadly, in a presentation on recent research, a renowned EMS scholar presented information on fluid resuscitation in sepsis that is not only not current, but may even be contraindicated by more recent research.  Sadly, some of the best airway education was occurring in the exhibit hall practicing the SALAD technique with disciples of anesthesiologist and EMS airway physician Dr. Jim DuCanto.

I wasn’t going to gripe about this until seeing my friend and EMS airway ninja post some excellent education online regarding surgical airways and the need to rapidly move to a surgical airway. I asked myself why a presentation like this didn’t occur at a major EMS conference.  I came up with three reasons.

  1. Audience.  Truth be told, not everyone in EMS wants to learn the most current medicine.  There’s a large, loud contingent of folks who want to learn the bare minimum to maintain certification and/or pass the test. “Meets minimum standards” is a mantra in EMS.  And as we’ve all heard me gripe before, you can never go wrong in overestimating the number of people in EMS who are in it for the hero status as opposed to the medical professional status.  See also: EMS t-shirt sales.
  2. EMS celebrities. Truth be told as well, there are certain speakers on the EMS conference circuit who are known quantities.  They’re entertainers first and educators last.  They fill the seats and are like flypaper attracting the “meets minimum standards” crowd.  These people can speak on any topic, present dated or questionable information, and have limited expertise on the topic.  But because they’re funny and/or appeal to the lowest common denominator, EMS conferences continue to invite them as speakers.  Why?  Because they put butts in the seats.
  3. Timing. Most of these conferences put out calls for presentations almost a year before the conference commences. As such, the most current research and practice doesn’t always make it in time.

If you wonder why I spend so much time on EMS social media and blogs, I will close things out with a quote from Dr. Joe Lex, the intellectual godfather of #FOAM.

If you want to know how we practiced medicine 5 years ago, read a textbook.
If you want to know how we practiced medicine 2 years ago, read a journal.
If you want to know how we practice medicine now, go to a (good) conference.
If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM.

And if you don’t know #FOAM, it’s likely you’re already a step behind the EMS education curve.

Do Something!

Late Sunday night, a madman killed people in Las Vegas.  Predictably, both sides have drawn their lines in the sand and demand that politicians “DO SOMETHING!”  Those on the left demand that politicians enact gun control and hector, cajole, shame, and belittle those who don’t believe as they do.  Conservatives argue that gun control doesn’t work and that the solution doesn’t include disarming the public.

In the spirit of full disclosure, I tend more toward the conservative view of things. I also have a Texas license to carry a firearm and do carry.  But I’m also a realist.  I doubt that a person carrying a handgun can stop a situation like in Las Vegas where a rifle is being shot from a high place at a large crowd.  Individual street crimes may be a different situation, but even in those cases, a “good guy with a gun” can only do so much.

So, we all want to “DO SOMETHING.” Here’s my opinion.  You can absolutely do something above and beyond “thoughts and prayers,” changing your profile picture on Facebook, or contacting your politicians for or against guns.  First things first. Learn some basic life-saving skills.  Learn CPR.  Learn basic first aid.  Learn bleeding control — including how to use a tourniquet.  And make sure you have current supplies at your home and/or in your car.  Some basic gauze, gloves, and a tourniquet can go a long way to make sure that a violent assault doesn’t become a homicide.  As an added bonus, your knowledge of CPR and first aid is valuable in other situations above and beyond shootings.  Car wrecks and sudden cardiac arrest kill just like a shooting — and a concealed firearm isn’t as useful in those situations. There are plenty of first aid and CPR classes out there.  If you can’t find one or have questions, feel free to ask me — or ask your local EMS organization.  You do know who your local EMS organization is, right?

Next.  You do need to contact your politicians.  But not necessarily about guns.  Ensure that your community has a well-funded EMS system and trauma facilities. Too many communities rely on the “low bidder” to provide 911 response.  Too many communities are holding bake sales so that their volunteer fire and EMS organizations can have the bare minimum equipment.  We can always have a debate about the role and scope of government and taxes.  However, all but the most radical anarchists or extreme libertarians would agree that a fundamental role of government is to send help when you call 911.  A high-quality EMS system is not a luxury.  Whether a car wreck, a mass shooting, or chest pain, the fact remains that early access to definitive care saves lives.  An Emergency Medical Services system does exactly that. For all of the comments on social media about so-called “First World Problems,” Americans should demand a quality EMS system that ensures access to clinically current, professionally delivered, compassionate medical care 24/7.

And if you still want to “DO SOMETHING,” consider getting training and volunteering.  The reality is that you might be near a volunteer fire or EMS department that needs people and just might even train you.  A basic first responder course is often less than 80 hours.

These are the steps you can take to “DO SOMETHING.”  Or you can keep changing your profile picture on Facebook.  The choice is yours.  Choose wisely.

Longhorn Student EMS

The University of Texas has decided not to provide insurance or legal protection to a student EMS group on campus.  Since this is my alma mater, I felt compelled to share my $0.02 with University of Texas President Gregory Fenves.  If you feel compelled to reach out, do so (and keep it polite).  He can be emailed at [email protected]

Dear President Fenves:

It’s rare that I find myself writing an email that hits multiple areas of who I am – a Texan, a Longhorn (BA 1996), an attorney, and a paramedic.  But the decision of the University to deny funding for Longhorn EMS’s liability insurance and/or assumption of liability hits home for me.

The University of Texas and the University of Texas System are blessed with many outstanding attorneys, both of counsel to the University and the System and throughout the faculty.  I would never take away from their counsel or guidance, but I would note to you that the liability for the provision of emergency medical services in Texas, especially by a governmental entity, is exceptionally limited. Texas Civil Practices and Remedies Codes §§74.151-74.154 and Texas Health and Safety Code §773.009 provide broad protection and multiple Texas appellate court decisions have broadened said liability protection.  As such, I would assert that the legal liability for the provision of emergency medical services, particularly at the EMT/basic life support level, is exceptionally limited and that the costs of any liability insurance would reflect such limited exposure. In short, this concern about legal liability on behalf of the University is a red herring at best.

University spokesperson Bird’s statements that the University wants students to be students and not to take on potentially dangerous professional responsibilities is, at best, ignorant of many students who are already certified as EMS personnel or might even be in the armed services.  Wanting students to be students first ignores that many students already are working including as employees of the University. Several UT students already work as emergency medical services providers in other venues even including as employees of the organizations that provide EMS coverage for University athletic events.  Additionally, many students of the University already volunteer in many campus organizations, several of which provide direct services for the University. And finally, there’s the eight hundred pound gorilla in the room that shatters the illusion that students should be only students – namely, men’s and women’s intercollegiate athletics. I am pretty certain that the time involved to become an emergency medical technician and remain active with a student EMS organization is a small commitment in comparison to the time that student athletes spend in service to the University.

From a public safety standpoint, having an on campus EMS system makes sense.  Even on an urban campus like the University, EMS response time takes time. The closest Austin Fire Department stations to campus, Station 2 on Martin Luther King, Jr. Boulevard and Station 3 on West 30th Street do not have ambulances.  The closest ambulance, if available for assignment, is Medic 3, located in the parking garage of the old Brackenridge Hospital.  At best, there is a delay in getting emergency care to campus.  Having responded to the University campus as an EMS provider, I can tell you that calls on campus are a challenge, especially in getting emergency resources to the right location because of the combination of obstacles in terms of vehicle access, determining the right location, and getting access/entry into University buildings, many of which are secured.  In a critical emergency such as cardiac arrest, severe allergic reaction, or uncontrolled bleeding, having a trained set of hands on scene sooner can, will, and does regularly make a significant difference in patient outcome.  In some cases, that difference in patient outcome is life as opposed to death.  Waiting for City of Austin resources and also waiting for someone from the University to provide access to a building just doesn’t make sense. And in case of a severe emergency or disaster, having “all hands on deck” and a force multiplier in the form of a University recognized and accredited group of EMS providers can and does make a difference.

The University has always encouraged public service.

As an undergraduate government major, my spirit of public service and engagement was encouraged and nourished by Dr. Janice May’s classes on state government and her public service internship program which gave me a foundation and prepared me for a career in state government. Especially as the University develops its own medical school and expands its involvement in all aspects of healthcare, encouraging a student volunteer EMS program is a no-brainer decision.  Encouraging students to volunteer and to become engaged in healthcare is, plain and simple, an outgrowth of the University’s mission to educate.  Such a program should be encouraged, not stopped. Many notable physicians and healthcare leaders got their first exposure to EMS, medicine, and volunteerism through campus EMS programs.

Texas A&M University has long had a student-run EMS.  In fact, Texas A&M University has student-run EMS for university events as well as a separate EMS program that provides paramedic-level ambulance coverage for the university campus as well as providing mutual aid backup coverage to the cities of Bryan and College Station.  Rice University has a student-run EMS program operating under the supervision and guidance of their campus police department. Rice’s EMS program operates as a campus first response organization, providing advanced EMT level care until the arrival of the Houston Fire Department’s ambulances. Colleges and universities throughout the United States have campus EMS organizations.  In fact, there’s even a National Collegiate Emergency Medical Services Foundation that exists to guide and promote campus EMS programs.  At the University of Texas, we are a “University of the first class,” as described by Article 7, Section 10 of the Texas Constitution.  More bluntly, to quote our former athletic director, DeLoss Dodds, “We are the Joneses.”  The University of Texas shouldn’t take a back seat to anyone. And that includes providing emergency medical services to the University community and its visitors.

Bluntly, the idea of a student EMS on the Forty Acres has grown in fits and starts.  Good intentions alone are nowhere near enough. And some of the attempts to provide this service have been, at times, amateurish. That is why it’s even more imperative for the University to recognize, fund, and support this effort, if for no other reason than to provide the resources of the University to supervise these students and ensure that what goes on with this organization is a credit to and not a harm to the University.

If I may offer my services to you, the University, or these students, I stand ready to do so – as a volunteer.  I am a Texas licensed attorney, a Texas licensed (and nationally registered) paramedic, a Texas EMS instructor, and a proud Texas Ex.

I encourage you to reconsider the University’s decision and strongly commend you to take steps to help this fledgling EMS program get the right start it needs.

Respectfully submitted (and Hook Em Horns!).

 

Part of being a clinician

Today, I heard from a good friend of mine who happens to be a good paramedic out of state.  They were telling me about issues with a family member who’s in the hospital and in poor condition.  Part of this involved the communication from the hospitalist who asked if the family member had a do not resuscitate order because the family member in question is “very sick” and without a DNR order, the patient’s ribs would be broken during CPR and “her insides would be messed up.”

I’ve dealt with similar conversations before both as a medical provider and as a family member.  Without going into my rant against hospitalists (who don’t know the patient outside of the hospital, rarely have an idea as to the patient’s baseline, and are often the bottom of barrel clinically and academically), this is completely unacceptable.

However, I will say that this is how people in medicine get sued. Not because their medicine hurt or helped. But because they have zero idea how to communicate with people. There are way too many physicians who have a pure science background and see patients as lab values on paper. They see patients and their families as a distraction. Likewise, there are way too many in EMS who are bitter because they were promised a chance to race the reaper and save lives and taking care of sick people isn’t “what they signed up for.” I am far from religious and definitely not Christian, but the verse from the Gospel of Matthew says it all. “I was sick and you visited me.” Ultimately, that’s what being a clinician is about. Taking care of sick people. Not flashing lights or even geeking out over lab values. And caring (and dare I say ministering) for the sick means caring for their family too.

I see way too many physicians who have a gift for the sciences and not a gift for communication.  I see way too many in EMS who can improvise a solution to make MacGyver proud but who make Chuck Norris look sensitive and compassionate. Medicine is not a pure science, no matter what anyone says.  It’s a profession.  Whether you’re a brand new EMT or a tenured medical school professor with subspecialty certification, you’re a professional using your scientific knowledge to solve human problems.  And human problems require interacting with humans.  Part of that interaction means communicating with other people, not all of whom you may like or who you may think are as smart as you are or even worth your time.

And the human factor in any profession, especially including medicine, is why professions aren’t mere sciences.  Yes, there’s a ton of science in medicine.  It is the foundation for much of what we do.  But we apply this knowledge to help others.  And helping others goes significantly beyond acid-base balances, covalent bonds, thermodynamics, or gas laws. It’s about demonstrating a bit of compassion and empathy.

You don’t necessarily learn those things in a science lab.  You learn them from interacting with others.  You learn these things in a liberal arts classroom where your views about the world are challenged, where you learn to defend your views, where you learn to maybe change your views, and most importantly, where you learn to communicate and get along with others.

Medicine — at any level — is ultimately a people profession.  If you’re not comfortable with people, you’re not likely to succeed.  It’s why EMS clinical evaluations are supposed to include an “affective domain” aspect.  And this is why I think that the constant drumbeat for more “science” classes in EMS also needs to be tempered with more classes in English, psychology, sociology, history, geography, and management.  In other words, being a solid clinician requires understanding people as much as it does the science.

And to add in my legal advice, people rarely know if you’re good at what you do.  They do know whether or not you’re nice to them.  And many of these cases of being “not nice” often involve poor or failed communications with the patient and/or their family.  Learning how to talk to others, whether to get information or to persuade, was a significant part of my education as a legal professional.  It needs to be a significant part of our EMS education as well — and that means more than rapidly brushing through the mnemonics of “SAMPLE” and “OPQRST.”  It means active listening and then incorporating that information with your scientific knowledge to actually care for your patient.

That’s what being a professional is about. That’s what being a clinician is about.  It’s not about the flashing lights.  It’s not about the lab values.  It’s not about an obscure EKG finding.  It is about caring for others.  Period.

What’s Wrong

This morning, I received a long email from a long-time mentor of mine who’s also a paramedic and attorney.  He was pretty upset about the lack of involvement from physicians in improving the state of EMS.  As I replied, I realized that I needed to adapt my reply to share with my three or four devoted followers.

I blame the docs too, but only tangentially.  They write protocols for the lowest common denominator.  They are risk averse and rightfully so.  There’s a lot of good paramedics out there, but there’s even more who shouldn’t even be trusted with a BVM (which I still think is the most dangerous and under-respected tool on the ambulance).  It goes back some to education.  We have way too many people teaching EMS education whose only expertise is that they hold an EMS certification. Law school and medical school aren’t taught the entire way through by the same someone with a JD or MD.  There are multiple classes, each taught by subject matter experts.  One of the things I hear from some of the EMS dinosaur types is how some of their classes were taught by physicians (including specialists) and nurses.  We don’t have that anymore and I think the education has suffered as a result.  CoAEMSP doesn’t care. They care that you’re using FISDAP or “Platinum Planner” to track your students and develop more metrics. They don’t care about the quality of the content.  NAEMSE doesn’t care.  They are too busy promoting “flipped classrooms,” “learning styles,” or whatever other trendy topics are out there.  The NAEMT doesn’t care.  They’re too busy promoting new card courses to cover things that should’ve been covered in initial education.  The American Heart Association doesn’t care.  They’re too busy promoting ACLS, BLS, and PALS to care.  And the NREMT?  They should care, but they don’t.  They will get the usual professional EMS committee members in a room and issue high and mighty statements about the EMS Agenda Version Whatever.  And the item writing committees for the exams will give a de facto veto to the state with the worst EMS standards because the exam “has to reflect the entire country.”  And the publishers of EMS texts don’t care.  They know their market.  Truth be told, there’s more people reading at a tenth grade reading level who are getting their paramedic because their fire department requires it than there are students (or teachers) who really want to understand the whys of prehospital medicine.  And the students and educators that do want to know how to practice prehospital medicine are supplementing their texts with medical and nursing texts as well as online material. The state health bureaucracies don’t care.  EMS is a small part of their mission.  They see their mission as public health and welfare — and to the average bureaucrat with a RN and a MPH degree, EMS is best seen and not heard — and then, only seen during EMS Week.  The Feds?  Well, truth be told, EMS really isn’t a Federal responsibility and making it such will ensure that the same people who brought us the VA will be in charge of prehospital medicine as well.
And don’t even get me started about the usual gang of idiots.  In short, every EMS committee is tasked to solve the ongoing problems of EMS but is full of the same EMS celebrities who created the problem in the first place.
EMS as a whole is beyond repair.  But virtually no single EMS system (except maybe perhaps some of the large urban systems) is beyond salvage.  Fix each system and fix the individual EMS education programs and eventually, the rising tide will lift all boats.
Until then, rant globally, fix locally.

Things You Need To Know

As an EMS provider, there are a lot of things you need to know. Many of them are clinical things about the practice of medicine that a lot of people who are a lot smarter than me can teach.  But for your reading pleasure and hopefully, for your education, here are some other things I’ve learned.

1) Most of your patients have no idea if you know what you’re doing.  They do know if you’re nice.

2) I spent a great deal of my time in EMS looking for the perfect EMS system.  I found out more than once that such a system doesn’t exist. Find the system that works for you (or that you can make work for you).  You’ll be infinitely happier in the long run.

3) It’s important to be current and correct on the practice of EMS.  It’s less important letting others know you’re correct. Corollary to this axiom: If you do need to coach or correct others, there’s an art to doing it.

4) EMS as it exists now in the USA has only been a thing for 45 years or so.  It’s still growing. And I think most of us are impatient. I know I am. But one thing I continually have to remind me myself is that EMS is still growing and maturing. Whether its your EMS system or another, it isn’t going to magically improve overnight or reach the level we know it can overnight. Continual gradual improvement is a thing. And in some systems, that improvement is showing. It’s just not going to happen immediately.

5) Your mentors will change. As we grow and mature in our practice, we find that some of the people we idolized aren’t as smart as we first thought.  And that’s ok too.

6) Knowing what to do is easy.  Knowing when to do it or not do it is the hard part of being a clinician.

7) Taking a patient to a hospital incapable of managing their condition is a disservice to the patient.  Part of being an EMS provider is that we are supposed to know where to take our patients.

8) This is actually supposed to be fun. When it’s no longer consistently fun, it’s time.

9) A significant portion of our time in EMS is spent dealing with emergencies.  The patient defines emergency.  We don’t.  And our education fails to recognize what patients consider emergencies.

10) A preceptor once told me that the paramedic’s job is to bring order to chaos.  If you can combine that skill with the passion and zest that most rookies and volunteers have along with being current on medicine and slaying dogma, you’re on your way.

Bread And Butter

Today’s blog post (and sorry for the delay to my Mom and the two others who read the blog) was going to be about continuing education.  I was going to write about the seeming inability to get the majority of EMS providers to engage in continuing education above and beyond the usual “required” card courses and/or the state-mandated refresher course material.  (Parenthetical.  I’m very glad to practice prehospital medicine in the Lone Star State where the state mandates very little as far as specific content and leaves it up to the provider as to what continuing education to seek out, subject to a few broad categories.)

I was going to complain about people not attending high quality continuing education, even when it’s offered for free.  I was going to mention the challenge of bringing the knowledge from international and national conferences like SMACC and EMSWorldExpo back to one’s home EMS system.  I was going to mention what I call the “Goldilocks” challenge of EMS continuing education — ensuring that the material isn’t so introductory to be a rehash of EMT classes but isn’t so complex as to require a PhD in pharmacology and physiology to understand the material, let alone apply it. I could even mention the whole volunteer versus paid debate, not even mentioning how so many volunteers manage to attend outside continuing education and conferences on their own dime, but you’ll rarely see a large EMS system (let alone a fire-based EMS system) sending people to a conference, let alone their members attending on their own. (See also: If I need to know it, they’ll do it in-house and pay me overtime for it.)

These are all worth mentioning.  And they deserve mentioning.  But here’s what really struck me. We can have all of the high-speed providers going to courses like these.  And there’s also going to be a lot of people going to “cool” sounding continuing education courses in tactical medicine, hazmat, or some sort of technical rescue. (Please, please tell me why an EMT working interfacility transfers needs to know how to be an “operator” in the hot zone.) But we rarely have good, consistent, clinically current, relevant continuing education on the topics that are the bread and butter of prehospital medicine. Think about your last shift on the ambulance.  Chest pain, respiratory difficulty, sepsis, ground level falls, abdominal pain, routine MVCs.  How much continuing education have you received on these matters? If you did receive continuing education on these topics, was it merely a repeat of what you’ve been told every recertification cycle you’ve been in EMS? From the amount of providers who think that any heart rate above 120 must be some form of arrhythmia that requires treatment and who think that EMS administration of diuretics for CHF patients is a good idea, clearly, we’re not getting the bread and butter of EMS down, much less mastering it.

What we see with continuing education is but a symptom of what’s wrong with EMS.  We want to do all the new cool things of the moment, whether it’s community paramedicine, technical rescue, tactical medicine, or critical care medicine.  We don’t want to do the bread and butter of medicine (see also: every EMS social media forum complaining about system abuse, drug abusers, or “frequent flyers”) and when we do the bread and butter, we aren’t always current.  If we can’t get the routine right, why should we be trusted with thinking outside the box?

A Time To NOT Volunteer

If you know me or you’ve come by this blog a few times, you know I’m very passionate about the role of volunteers in the world of emergency services, particularly in the fire and EMS world.  Today marks a change.  One, I’m about to give some very broad, generic “free” legal advice.  Two, I’m about to tell you NOT to volunteer.

Event medical standbys. At least in Texas, those fall into a massive loophole where they’re not subject to any regulation from the state. In Texas, transport providers (officially called “EMS Providers”) and “first responder organizations” are subject to state regulatory requirements.  Because event medical standbys don’t fit into Texas’s definition of EMS Provider or First Responder Organization, they’re completely outside the purview of our state EMS regulatory system.

These events always say “BLS only” or “CPR/first aid” but seem to recruit heavily from the ranks of EMS providers. If they truly only want “BLS” or layperson aid, why are they recruiting so heavily from EMS?  Simple.  They want EMS providers on site, but they’ve gotten some legal or risk management advice to not call it an “EMS standby.”  They think that by saying it’s only first aid that their liability will somehow be limited.  Truth be told, I’m not sure if it would or wouldn’t be limited.  But I know this much from law school — anyone that can be sued will be sued, both collectively and individually.  While you may not end up being found liable, I can guarantee that will not protect you from either a suit or the lawyer’s bills to represent you.  (Speaking of which, you do have your own EMS liability insurance to protect you and provide for legal representation, don’t you?)

This is the closest you’ll ever get to free legal advice from me. Just say no. You’re unlikely covered by any medical direction or protocols, which begs the question of what you’re doing there and whether you’re practicing “medicine” or delivering EMS care. And if all they want is “BLS” or first aid, why are they asking you to be there by virtue of you holding an EMS certification? I’ve helped at these events before and it feels very odd to be there without the ability to function at your certification level, assuming they’ve even verified your certification.

In the very best case, you’re probably going to be poorly equipped.  You’re even more likely to be expected to supply your own gear. And I will virtually guarantee that if something bad happens, you will be on your own. The worst part? Many of these events are for profit. Those that aren’t are usually run by nonprofits that have plenty of money for everything besides real EMS coverage. Many of these so-called event medicine companies have a business model based on you being an “independent contractor,” meaning that they’ll throw you to the sharks and claim that they had no oversight of you.  In other words, helping some of these events out for free as a “volunteer” isn’t much better than offering to drive Lyft or Uber for free.

If you truly want to “feel good” by volunteering, get a t-shirt, and/or be thanked for your service, there’s probably a volunteer service within an hour’s drive of you that would actually benefit from your volunteer hours. To me, it’s really ironic is how many paid firefighters/EMTs jump at the chance to work at these events and then say how volunteering “holds back the profession” and artificially lowers salaries.  If that’s the case, then it’s high time that we tell each and every one of these large public events that they need to provide EMS coverage just like they have porta-potties, trash collection, food service, and security on site.

Want to Volunteer?

Anyone who knows me knows that I’m pretty passionate about my volunteer work in EMS.  To me, it’s a wonderful way to give back and it’s a wonderful change of pace from my workday of moving contracts through the bureaucracy.

Those of us in the fire and EMS world hear a lot about the supposed shortage of volunteers.  Last week, I saw the irony of a state volunteer fire association doing a media outreach at the state capitol using trucks from a department that is primarily paid and doesn’t even have information on its webpage about volunteer recruitment.

So, in the spirit of an intervention filled with tough love, I offer you the following advice.

Want to join a volunteer fire or EMS department? Let’s talk about what happens.
1) Good luck finding the department online. If you do find them online, good luck finding an application.

2) If you do apply, you can expect some sort of committee process to see if you “fit in” with the prevailing culture of the department, which is probably dysfunctional.

3) If you have no interest in 80% of the fire department’s calls being medical, no worries. You don’t have to even get your first responder. But even if you already have your EMT or Paramedic, we will demand that you be a firefighter.

4) Training? What’s that? We’ll do training when we feel like it, on topics that only interest us, conducted by people with no qualifications. If you need additional training to maintain your certifications, that’s probably going to be on your own, with your own money.  But if the training sounds “cool,” you can fully expect that the connected members of the department will be travelling to it — on the department’s dime.

5) Equipment?  Yeah…. Here’s a t-shirt or two. We’ll issue you a radio, pager, safety apparel, and EMS equipment sometime, maybe — if we like you and/or you still keep coming around after putting up with us.

6) Leadership?  What’s that?  We’re likely run by a self-perpetuating group of insiders who are completely insular in our thinking and definitely don’t wear how anyplace else does things, especially from you, the new guy.

7) You’ll be on some sort of probationary process for a while, which will be a form of institutionalized hazing until we “check you off.”  Good luck getting one or two of the very specific training classes that you need to be released from probation.  We only offer those every few months at best.

8) We will continue the same things we’ve been doing for 40+ years, then wonder why we can’t find volunteers.

9) If we have paid guys, they’ll unionize and then claim that they can’t work with volunteers.

10) We will beg and plead everywhere for volunteers, show zero flexibility, and use that as political cover to put in another tax levy to pay for more unionized firefighters. Once we do that, we’ll then try to become an “all-hazards” department and get ambulances staffed by 18-25 year old firefighter/medics who want to do suppression only.

If you find a department where the majority of these thing don’t apply, stay there.  You’ve found a gem.