We keep seeing the pleas and exhortations to “pay EMS workers what they deserve.” I get it. We’re underpaid. Or so we keep hearing.
Whether we are employed by a public or private entity, we’re still a business. We get paid for our services, whether through tax money, patients’ payments, or reimbursement through private or public insurance. That means that we’re selling what we do — and if we don’t have customers, we don’t have ambulances — or paychecks.
The number one goal of any business is to have (and keep) customers. (Of course, there is an exception to every rule and in the USA, the businesses that don’t understand customer retention are cable companies and cell phone providers!) And the truth be told, we in EMS do a terrible job of gaining and keeping customers.
Let’s talk about gaining customers. The fire service and law enforcement get it. They routinely engage in public relations, outreach, and public education. These organizations go out of their way to make themselves visible and engage the community in almost way they can. If a citizen shows up at a fire station, you can almost guarantee they’ll be offered a tour, a cup of coffee, and a warm greeting. Show up at an EMS station and what happens? Probably a grunt, at best. Fire Prevention Week? The firefighters are making the rounds. National Night Out? The cops will be there. And probably the firefighters too. Social media? Most PDs and FDs have Facebook pages where they share and brand their message? EMS? Not so much. We have EMS Week? What do we do? Well, for one thing, we complain about whatever “freebies” the hospitals give us. Maybe we’ll put a crew somewhere and give the same blood pressure checks you can get any day in the waiting areas for most pharmacies. Ride-alongs? Sure, some organizations allow them. Many don’t, claiming HIPAA, liability, or some other red herring. Showing off the ambulance? Explaining EMS training? Nope, most places don’t do that either. Wonder why people confuse EMTs and paramedics or just call us ambulance drivers? Wonder why people call us for non-acute reasons and then drive themselves to the ER when it’s a “real” emergency? The reason is simple ignorance. Ignorance can be cured. But we’re too content to complain as opposed to educate. Most PDs and many FDs have a “citizens’ academy” program where they provide the public an insight into their world. With the exception of MedStar in Fort Worth, I’ve yet to see an EMS program do this. But again, we complain at the lack of respect given to us.
The lack of respect given to us. Yep, we complain about that all the time. But do we show any respect to our customers? Yep. Customers. And if we have customers, we have to have customer service. I could spend hours on customer service. But I won’t, because I can distill it into two key takeaways. First, be nice. Second is “why be nice?” The simple reason is that nice providers are less likely to be complained on and even sued. The reality is that the overwhelming majority of our patients don’t know anything about the quality of our care. What they do know about is how nice we are to them. Please, thank you, sir, and ma’am go a long way — as does a genuine attitude of caring.
Of course, I’m probably preaching to the choir here, but maybe we need a “card course” for customer service. In conclusion, we all complain (INCLUDING ME) about how fast food workers don’t deserve $15/hour because they don’t get our orders right. Maybe we don’t deserve $15/hour yet either — because we don’t educate people as to our worth nor do we treat people like customers.
The next time you deal with the public, remind yourself one thing. They’re a customer. And without customers, there is no EMS.
Let’s be honest. EMS culture at some times can be toxic. We have a ton of stations where gossip, a “good old boys” club, a “mean girls” club, or hazing occupy the down time and set a horrendous tone. In too many EMS organizations, the precepting and field training processes become a bad parody of some sort of boot camp environment where breaking down a new student or provider, hazing, belittling then, or teaching them merely to practice medicine exactly as their training officer is the sad norm of things. I get it. We’ve got a culture problem in EMS and we can all improve.
Many of our new students and providers are coming out of college-based programs. (One result of the accreditation process, whether intentional or unintentional, beneficial or harmful, is that college-based programs are more likely to have the infrastructure and resources to navigate and succeed in the accreditation progress.) There’s been a lot of discussion about the current “snowflake” or “cupcake” culture and how many students want validation. While my experience is merely anecdotal, one of the words that I see students and new providers abuse is the word “supportive.”
I routinely see/hear/observe people using the word supportive to mean that they only seek validation. They use the word to stifle any criticism and to discourage dissent. The reality is that, maudlin posts and attention seeking memes aside, the practice of medicine (and that does include EMS) is serious business. We’ve been given a position of trust, responsibility, and even some authority. That means there are right and wrong answers in what we do. There are very real consequences to much of what we do.
In short, it’s each of our responsibilities to be supportive. But it’s also our obligation to ensure that supportive doesn’t become a way to validate and enable poor providers. Supportive should never mean a lack of accountability. Each of us do have a responsibility to “enable” our students and new colleagues — and that should be to enable to become the best clinician possible. Nothing else is acceptable.
Recently, I’ve seen more than a few EMS types posting requests for crowdfunding for them to engage in medical work, either as a medical missionary or in solidarity with various protest movements. I get it. The urge to help others, especially in moments of extreme need, is a huge motivator for many of us in public safety or medicine. (And yes, that’s controversial right there. EMS is a mix of public safety and medicine. We use a public safety model to deliver medical care. Prehospital care is what I like to call “operational medicine.”)
But, to me, asking for crowdfunding to subsidize your passion reeks of so much that I don’t like about EMS. There’s a vocal portion of people in EMS who are all about “LOOK AT ME! VALIDATE MY EXISTENCE! I’M DOING SOMETHING NOBLE AND YOU SHOULD APPRECIATE ME!” It’s so common throughout EMS, as we see with the t-shirt and bumper sticker brigade. I get it. We want to help. But it seems that, for a vocal portion of EMS providers, we only want to help when we’re getting attention. (Bonus points if you appeal to social justice and get subsidized for being a medical activist…)
Bluntly, if you’re having to get others to pay for your altruism, you probably aren’t in a financial situation to be taking the time off to travel to a faraway land, whether overseas or even in the USA. It’s, at best, highly irresponsible.
The honest-to-God (or insert your deity of choice) truth is that there’s plenty of places local to each of us without access to medical care. Heck, there’s plenty of places within an hour’s distance of each of us that are probably lacking access to quality EMS care and would love to have a passionate, dedicated volunteer provider on board.
Way too many folks in EMS make fun of volunteers and claim that volunteers are responsible for poor EMS standards and low wages. Yet way too many people in EMS volunteer — when it gets them attention and a partially funded trip out of town.
As the old saying goes, charity begins at home. Find your local service or local medical organization where you can begin to address the lack of care locally. Ok, rant over.
I’ve been away from the blog a bit, mainly as a result of some writer’s block. With an upcoming trip to the Texas EMS Conference to speak (Tuesday, November 22 at 2:00 PM, by the way) and to get some continuing education, I’m more rejuvenated about EMS than usual. And then, tonight, I heard from a dear friend of mine who works for a large, urban third-service EMS system in Texas.
She proceeded to tell me about her patient earlier this evening (without violating patient confidentiality), while working a high-volume truck in the inner city. Her patient needed to go to the hospital for treatment of an illness that had been lingering for a long time. She made arrangements to have all of the patients’ belongings moved as that was one of his objections to getting care. She then administered pain medicine because “that looked like it <expletive> hurt.”
Honestly, it’s what we’re supposed to do. But a lot of us miss the mark. But ultimately, she took care of a patient, got them to care, addressed their pain, and gave them a bit of dignity. Stories like this don’t make the news. They don’t make great t-shirt slogans. But taking care of the least among us is exactly what EMS is supposed to be all about. Things like this remind me why it’s a privilege to be a medic and why it’s truly a sacred honor to take care of patients.
I’m not a Bible verse kind of guy, but her patient care tonight reminds me of this verse, “whatever you did for one of the least of these brothers and sisters of mine, you did for me.” And ultimately, that’s the standard we should strive for as medics, as public servants, as caregivers, and as human beings.
There’s a lot of enthusiasm on EMS social media and some of the most enthusiastic of these people want you to know just how much enthusiasm for EMS. There’s a lot of people saying how much they love being in EMS. There’s a lot of those people sharing pictures of ambulances, fire trucks, helicopters, and badges. These are usually the people who have all the cool sayings, catchphrases, and memes down. These are the ones about heroism, pride, sacrifice, and everything else all-American and apple pie. There’s also a group of marketing types who make a fair amount of money selling T-shirts to those enthusiastic EMS types.
Here’s what I never see from those types. I rarely see why they’re enthusiastic about EMS. And I never see their enthusiasm about the MS of EMS — medical service. These people are never at the EMS conferences, except at the vendor’s booths getting their latest “Big Johnson EMS” t-shirt. If they go to continuing education, it’s because it’s mandated. They share the hero stuff. They don’t share the medical stuff. And what they do share about medicine falls into two typical categories — war stories and dogma. For them, it’s even better if they can share both. “There I was, taking this guy to the ER who’d slipped and fell. Good thing we put him in a C-collar and a backboard because he had a hairline fracture of C-3. You can’t ever be too careful.” These are the same people who believe that cutting edge medicine involves a backboard, a non-rebreather mask, and a diesel bolus.
I’m enthusiastic about EMS. What I love is that it’s an opportunity to help someone and provide medical care when someone doesn’t know where else to turn. And to me, that opportunity to serve comes with an obligation to provide the best care possible. There’s an imperative to be up on the medicine.
EMS social media is a phenomenal tool for networking with like-minded providers and to share the latest developments in medicine. I am incredibly thankful to some great, smart EMS professionals online who’ve shared their tricks of the trade with me. I’ve learned more about Ketamine, sepsis, rapid sequence intubation, push dose pressors, and countless other topics from the online EMS world than a hundred local classes could ever have attempted to provide. And when I’ve despaired over things, whether in EMS in general or in my personal EMS world, there’s been a friend out there who’s shared the same frustrations. But social media friendships, just like “real world” friendships, are highly dependent on who you choose to associate with. As the old saying goes, “choose wisely.”
In conclusion, it’s great to be proud and enthusiastic to be in EMS. The challenge is to channel that enthusiasm into being a provider that provides a service to your patients. If not, you’re just another whacker. Don’t be that whacker.
I’ve gotten tired of the media. I’ve gotten tired of the same stories appealing to the uneducated masses. I’ve gotten tired of the same talking heads spreading the same talking points. You thought I was talking about the upcoming national election in November?
Wrong. I’ve gotten tired of the EMS media, both print and online. Virtually every EMS social media, online presence, and print publication consists of the same things. A few clinical “advances” highlighted, usually by a professional EMS Celebrity, the right EMS system, and/or the same cabal of professional committee members who’ve created the mess that is modern EMS — but wait, this time, they’re really going to fix it. Then, there’s all the stuff to tell you what a hero you are. Yes, you should wear your lack of education, your immaturity, and your inability to feed a family on an EMT paycheck as a badge of honor. And the majority of EMS “news” sites consist of results of content searches. If a news article mentions “EMS” or other keywords, it gets shared on EMS news sites. In my mind, this partially explains the Narcan for everyone craze — because, golly gee, they keep reporting on heroin and other scary drugs.
And EMS social media is more of the same. Pandering to the least educated of the profession mixed in with some hero worship and mindless adulation because merely going to a job that involves less than 200 hours of initial education makes you a hero. And by God, if you can’t pass an exam that measures minimal entry level competence to safely function, then don’t worry. We’ll keep encouraging you and tell you to keep chasing those dreams, no matter how unrealistic they are, you special snowflake!
At times, you’ll see EMS media get it right. The cover of the current edition EMS World is about prehospital ultrasound. Some of my friends in EMS who want to advance EMS as a profession and expand the role of EMS providers have tried, with occasional success, to raise the bar. Yet, the reality is that there’s always more average and below average EMS providers to consume the media. And in a capitalist society, we go where the money is.
I don’t know that we can fix the problem. What I do know is that there is plenty of good educational material out there to be an informed, current provider. You just have to look for it. There’s even some good stuff online. If you’re not familiar with FOAM, you should be. There’s some incredible cutting edge medicine being spread on social media. I like the quote that Dr. Joe Lex says:
If you want to know how we practiced medicine 5 years ago, read a textbook.
If you want to know how we practiced medicine 2 years ago, read a journal.
If you want to know how we practice medicine now, go to a (good) conference.
If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM.
And that brings me to the final point that I have regarding becoming and remaining an informed practitioner of prehospital medicine. If what we are doing is medicine — and I believe it is, then we need to be getting our education from physicians. I admit to being a nerd about medicine. I have several physician level texts that I use to expand, broaden, and challenge my notions about medicine. And a personal goal is to attend more physician level professional education.
A rising tide may not always lift the rest of EMS, but I believe that if the smartest and most motivated of us in EMS demand more for our professional development, just maybe, we can start to be taken seriously as professionals.
I work in a profession with high rates of substance abuse, mental health challenges, and a high potential for burnout. I regularly hear how people in my profession don’t even realize they have these mental health challenges. It’s gotten so bad that my profession’s association in my state has created a peer support and referral network for substance abuse and mental health. You thought I was talking about EMS, didn’t you? Wrong. I’m also a lawyer and we are regularly warned about mental health issues involved with lawyers. (Nope, not going to put a lawyer joke here.) There’s also a ton of profession-specific outreach and awareness of mental health issues going on for physicians as well.
It’s VERY true that EMS has the potential for mental health challenges. We’d be improving if we said that EMS did a crummy job of addressing provider mental health. In too many organizations, mental health is ignored or paid lip service at best.
But we’re EMS. We are convinced that everything is all about us. ALL THE TIME. We wear t-shirts with slogans that confirm the worst about us being “ambulance drivers.” We constantly want you to know how special we are, whether it’s t-shirts or attention-seeking social media posts and memes about “racing the reapers,” how we “save lives,” or some other random “look at me” theme. So, when the less informed of us in EMS get interested in mental health, it’s the same thing.
The truth is that we’ve all seen things in EMS that no person should ever see. We are in a position of public trust where we get a ringside seat to the human condition at its ugliest. I’ll let you in on a secret. A lot of other people get to see some of this as well. Imagine what social workers dealing with the abuse of the elderly, the disabled, and children see. Imagine being a school teacher and dealing with the outcry of a child who’s been sexually abused or who’s coming to school hungry. Heck, imagine being a lawyer and being involved in a criminal trial for sexual abuse of a child or a civil case involving someone who made the decision to put profit ahead of the public. In other words: EMS isn’t as special or unique as we think. One of the biggest things that I learned from my psychologist is that the challenges I came to see her about were not unique. That alone was the biggest lesson I learned and the biggest thing that I remind myself daily. It’s a very liberating feeling to know that you’re not alone in your challenges. I think that EMS could collectively benefit from knowing that we’re not as special or unique as we think.
Mental health is a health issue. Period. It’s treatable. But first, it has to be diagnosed. BY AN ACTUAL MEDICAL PROFESSIONAL. There exists a subset of EMS providers who are convinced they have PTSD or some other mental health issue solely because they work in EMS and they wear it as a perverse badge of honor and martyrdom because “LOOK AT ME. I’M A HERO AND I WEAR THESE WOUNDS. LOOK AT ME!” Think about that for a second. I didn’t diagnose my own diabetes. My doctor did. She’s given me wonderful coping tools (namely dietary modifications and medications) to deal with this diagnosis and live my life as normally as I can. I don’t brag about being diabetic. I don’t seek attention because I’m diabetic. But there’s too many of us in EMS who wear a supposed mental health diagnosis like it’s a badge of honor or rite of passage in being a “real” medic.
I’m a lawyer. And the truth is, I love being a lawyer most days. There are days where it gets stressful, frustrating, or challenging. And you know what I do? Something other than being a lawyer. Whether it’s a road trip, time with family or friends, or even my passion of EMS, I do something other than being a lawyer. I recently saw a post on social media from a person worried about their mental health. They also work several EMS jobs and their profile has a typical “EMS hero” slogan on it. They need two things. 1) They need to see a qualified professional to make a diagnosis. They aren’t going to get a diagnosis on social media. 2) They need to restore their work-life balance. Take the time to do that which makes you the person that you are. And that’s not always EMS, law, or any other profession that you practice.
I apologize for the rant. I apologize for the indiscriminate use of capitalization. I apologize if you think I’m not being supportive. But I will never apologize for my belief that mental health in EMS (or life in general) is too important to be distilled into another meme. If you’re facing the challenges, get help. Real help. Professional help.
And one other thing. You’re more than your professional identity of being an EMT or a paramedic. Find that which recharges you. Find what makes you the person you are. When you’re off work, truly be off work. Maybe even take the time to hug someone in your family, your friend, or a significant other.
Some of my best ideas for discussion fodder come from EMS social media. Both the great insights and the “what was that guy thinking” moments get me to thinking about EMS and how we can “Make EMS Great Again.”
Today, several discussions led me to the topic of today’s blog entry for y’all. A good friend of mine was bemoaning the lack of critical thinking in EMS providers of all levels, particularly after reading yet another “experienced” paramedic say the worn out, discredited, incorrect cliché of “BLS before ALS” yet again. He suggested a need for an assessment and scenario based class on critical decision making, especially in relationship to airway management. Another smart paramedic commented on a need for a course in scene management. A few short moments later, I got an email advertising a textbook for a new NAEMT “card course” on “EMS Vehicle Operator Safety.” And several days prior, people were bemoaning the current state of EMS continuing education where mandatory “card courses” like CPR and ACLS are virtually impossible to fail, yet also devoid of much educational value. Then, there are all the new “tactical” classes for incidents unlikely to occur in your jurisdiction. Meanwhile EMS continuing education fails to keep providers current on the science and treatment of “bread and butter” EMS calls like respiratory distress, chest pain, abdominal pain, and routine trauma. But there are certifications for critical care medicine, flight medicine, tactical medicine, and community paramedicine. Before we reboot into EMS 3.0, let’s try to make sure that EMS 1.0 isn’t a completely flawed platform.
And then, all of these thoughts combined as I realized that they all, in part, address the same challenge. Namely, the idea of a “street ready” paramedic doesn’t exist. The National Registry exam, by its own admission, measures minimal entry level competence to safely practice. Most organizations have some sort of field training process. In these organizations, they usually run between one of two extremes. Some sort of quick orientation process that exists solely to say the new hire was “checked off” or some sort of extremely long process that is a virtual repeat of your EMS educational program’s clinicals where you are evaluated on clinical proficiency in each and every skill. And in all too many programs, the FTO process becomes a legalized hazing process where you perform to your FTO’s prejudices, biases, and whims. Having been through a variety of field training programs, I can say that what doesn’t exist is an orientation to things you might experience daily — how to use the two way radio, how to troubleshoot various pieces of equipment, how to get supplies, etc. And depending on where you’re employed, you may go weeks — or years — without being exposed to certain types of calls and patients to put in your personal library of encounters that you can call upon for the next patient care challenge.
As a new lawyer, I experienced many of the same frustrations. I came out of law school and the bar exam supposedly “ready to practice law.” But my first few years as a lawyer, I was really learning how to practice law. And I began to recall something that was discussed in law school – namely, there is no internship or residency for lawyers like there are for physicians.
As a paramedic who didn’t have to rely on a paycheck as a paramedic, I got lucky. I worked part-time for a while for a suburban service as I realized how little I actually knew. I then got VERY lucky to find a volunteer position with the service that made me the paramedic that I am today — Harris County Emergency Services District 1 (now called Harris County Emergency Corps). I walked into a perfect situation. At the time, the District utilized their volunteers primarily as third crew members on a truck. The paid staff usually appreciated an extra crew member to help. And there were plenty of crew members who were willing to take the time to teach and pass on lessons. It also didn’t hurt that the District was like the Bermuda Triangle of EMS. Calls happened at HCESD-1 that simply didn’t happen anywhere else. High acuity calls in an economically depressed inner city combined with access to the best hospital systems in Texas made this an ideal learning environment for a motivated paramedic wanting to truly learn their craft.
In other words, I walked into, without realizing it at the time, a virtual internship and residency in urban EMS. I remain convinced that my three years there made me a competent, motivated paramedic. I actually even remain in contact with several of my former colleagues.
I realize that the funding issues and operational issues remain out there, but don’t we owe it to our patients, and even more to our professional identity, to create paid internships and residencies in EMS where a new paramedic has a safety net of experienced providers to work with in the right environment to truly become a master clinician? Clearly, what we’re doing now is window dressing.
An internship program for EMS would create truly “street ready” paramedics. Having an opportunity to truly learn medicine, both clinically and operationally, functioning as a third crew member with an experienced mentor (NOT a FTO “checking you off”) in a high volume system would be a perfect transition from student to employee. If we can continue to tilt at windmills in EMS, like the quixotic quest to declare EMS an “essential government service,” why can’t we decide that we want providers who are truly ready to practice?
Let’s make the commitment for some high volume systems to serve as true training grounds for new paramedics to earn their spurs. It’s time.
For those of you who know me outside of this blog, you may know that I run several EMS groups on Facebook. Several are private groups for friends and colleagues, but one group has grown well beyond expectations.
Running an EMS page on social media is a constant challenge. I like to compare it to Goldilocks and her porridge tasting. Some porridge is too hot. Some is too cold. She had to try to find the right porridge.
EMS social media is the same way. There’s one extreme where we always have to be supportive. Everyone should follow their dream and passion to be in EMS, even if you’ve failed the National Registry exam three times. These people recite the dogma quotes we all cringe at. “BLS before ALS.” “EMTs save paramedics.” “Race the reaper.” Their sources of information include “my instructor told me” and “our protocols said.” If you challenge these folks, you’re automatically unsupportive and get called a “paragod.”
There’s an opposite extreme as well. These are the people who obsess and drone on about arcane clinical topics. No minutiae of biochemistry or pharmacology is too obscure for these pedants to emphasize that you’re “dangerous” if you don’t understand. These people, or their companions, like to post random EKGs with subtle findings that even cardiologists would debate. They will post these EKGs without any patient presentation and expect any EMS provider to find the zebra or risk their scorn and ridicule. It’s as if Sheldon and the rest of the cast of The Big Bang Theory started working on an ambulance and/or as EMS educators.
So, there’s a balance. The truth is, it shouldn’t be that hard to pass an entry level EMS exam which measures minimal competency. Mere certification determines entry level competency. We must always strive to be better, each and every day. It’s my personal belief that EMTs should be reading paramedic level material for continuing education and/or possibly considering pursing AEMT/Intermediate or paramedic certification. It’s my belief that paramedics should be reading physician-level educational material to supplement their knowledge. With the advent of open learning sources such as FOAMed and the like, the material is accessible. However, it’s also important that we remember our fundamental role in the world of medicine. In most cases, we are the entry into the healthcare system. If we can get the right patients to the right level of care the vast majority of the time, then EMS is a success. Don’t worry about the Krebs cycle nearly as much as you worry about taking care of your patient. I don’t expect the average EMS provider to provide physician level care or have a PhD’s understanding of the underlying science. I expect competent, compassionate care where a clinician recognizes their limits, but challenges themselves to expand those limits daily.
Medicine is a parallel to engineering. While both are based on the sciences, they are the application of pure science to solve human problems. Never forget that what we do is about people.
Having said my peace for now, I make one promise to you. I’ll try to be a better clinician, caregiver, and person today than I was yesterday. I merely ask that if you share a passion for EMS that you make the same commitment.