COVID 19, Free Money, and Excuses

This is a bit far afield from my usual blogging about the world of EMS, but if you think big picture above and beyond considering what clinical skills an EMT or paramedic should have, maybe this is exactly about EMS.
A couple of things about COVID-19 and business and government. As most of y’all know, I’m a practicing attorney with over 16 years of experience in government law, so I think I have some qualifications to comment.
 
1) In regards to the availability of the various loans, contracts, and grants, especially to small businesses and individuals that all levels of government are providing, it’s no surprise to me that they’re not getting where they need to be. Government moves slowly, even when it’s trying to move fast. And when it does move fast, it often fails to consider how the program will work. (See the current Paycheck Protection Program loans and how they seem to really overlook certain businesses, especially the restaurant business.) There’s an art to doing business with or getting money from the government and it usually takes a level of sophistication to navigate it. Sometimes, it’s not merit that gets the money as much as it’s the person or company that knows how to fill in the paperwork best. Early in my career in state government, the state agency that I worked for regularly contracted for advertising services for a public relations campaign. The company that regularly got the contract had hired one of our agency’s former office managers.  One of said manager’s duties prior to leaving state employment was reviewing contracts and preparing the bid and contract documents.  In other words, that company knew exactly which forms to fill out and what answers were expected on the document. And how does this relate to EMS?  Simple. Let’s think about some of the EMS grants out there.  We know that certain EMS agencies nationwide have the expertise to apply for grant funding.  These same agencies get every grant they apply for  Meanwhile, there are small EMS services struggling to keep supplies on the ambulance that have neither the time nor the savvy to navigate the grant process while at the same time, the right large systems get a WMD trailer, a HazMat truck, and a tactical medicine supply that would keep the Green Berets and SEALS stocked for the next ten years.  Or there’s a Federal grant program available only to certain types of recipients.  For example, a grant for EMS may only be available to local government entities or to fire-based departments and will completely overlook private non-profit departments.  Moral of the story?  It often takes a lawyer or at least someone savvy with the ways of government to tap into the “free government money” that the media reports on.  And just as surely as the media will report on two things after this pandemic goes away.  First, they’ll report on some entity that did or didn’t get the money and why that’s a travesty.  Next, when the pandemic stockpiles get recreated and funded, there will be a story within the next two years about “exposing government waste” and a “warehouse full of supplies that no one has ever used.”
2) Failures.  The truth is that COVID-19 is causing unprecedented failures, whether in business or healthcare. And those failures need to be documented and measured so that we don’t make the same mistakes in the next pandemic or disaster.  BUT… it’s also a convenient excuse for failure too. There are stories of deaths being attributed to COVID-19.  At least here in the Lone Star State, death certificates allow for the listing of contributing factors.  So, while COVID-19 might have killed someone, their underlying conditions may have contributed. Or maybe the underlying conditions killed the patient, but the COVID-19 contributed.  COVID-19 might be the cause of death or it might contribute.  This applies outside of medicine too. Lately, I’ve been reading about restaurants “closing due to COVID-19.”  Yes, COVID-19 was probably the final straw.  But if you had a business already in decline, maybe COVID-19 was only the contributing factor.  Or you could have self-inflicted factors caused by your own business decisions. See also the restaurant that refused to allow delivery services BEFORE the pandemic and then closed one of their locations, even for to-go orders, at the first quarantine action by local government. Business, especially the restaurant business, is a Darwinian process with low profit margins.  Relevance to EMS?  I’d also note that EMS is known for low financial margins and is heavily reliant on government funds, as is much of healthcare.  Throwing any disruption into this narrow financial margin and there’s bound to be a financial catastrophe. (See also: nursing homes) In short, it’s always easier to blame an outside event than your own failings and decisions. Case in point being a long time local restaurant deciding to close “due to COVID-19” at the same time that the owner planned to close in the next few months due to retirement and rising rents.
3) And I’ve saved the most controversial post for last.  Let’s talk about quarantines, “stay home, stay safe,” or the popular phrase “flatten the curve.” I am the absolute first to say that COVID-19 isn’t the flu.  It’s a literal pandemic.  And we know that, right now, there’s neither a cure nor a vaccine. As such, we have to take drastic actions to slow the spread of the disease, save lives, and equally importantly, save the foundations of our healthcare system. And to get people to take drastic action, we have to create a sense of urgency. As such, we’ve told people to stay home.  We’ve closed schools and offices and told people to work from home if they can.  We’ve made the decision to take a massive hit to the economy to spare lives and lessen the strain on our healthcare system.  That decision is a no-brainer.  It’s the right decision and it remains so, especially without either a cure or vaccine for this disease. But the models predicting catastrophe have changed and reduced their estimates.  Granted, some places in the United States, like the New York City corridor, have born a terrible price.  (Population density is a real curse in pandemics.) At this point, if ever, we’re unlikely to know if the decrease in deaths is due to our social distancing efforts, better treatment regimens, or a flawed modeling scheme. At some point, whether now or at a still to be determined time, we will have to reopen the country and our economy.  The cure for the pandemic may be the death of our economy.  Clearly, we’re going to have to address this — and smarter minds than my own will have to weigh in.  I am pleased that our political leadership is looking for advice from those outside of the medical field.  While the medicine is crucial in this discussion, my own experience is that the medical community, probably more than any other field I’ve been exposed to, tends to believe its knowledge of healthcare trumps all other concerns and their expertise on health requires immediate deference on all other fields. Regardless, I’ve noticed that our society has changed over the four decades that I’ve been around.  Whether its societal evolution, the 24 hour news cycle, or a climate where social media gives everyone, even the unqualified, the same ability to spread their opinion, we’ve changed. The biggest change I’ve noticed is that our modern society is afraid. We’ve grown to demand safety over all else and find any risk intolerable.  Risk must be mitigated to an infinitesimally small factor. In other words, Karen from Nextdoor has become the avatar of our society.
Sorry for the rambling and the massive diversion from the usual EMS discussions.  Or wait…. maybe this discussion of government, failures, and risk versus safety is EXACTLY what EMS needs to advance.  As I’ve harped more than once, the practice of medicine (including EMS) involves much more than scientific knowledge and clinical skills. Medicine is like engineering or architecture — it applies sciences to human problems.  As such, medicine has to factor in more than the hard sciences.
Thanks for listening.

Early Lessons/Thoughts From COVID-19 for EMS.

Because the science is evolving on COVID-19, we know that the end lessons from this may be different.  But I’d like to throw of my early observations out early for consideration.

First and foremost, all of the EMS grants, training, and attention paid to tactical EMS, mass shootings, explosives, and weapons of mass destruction, the real test and draining of EMS has come from an unrelenting call volume brought on by a novel, pandemic respiratory virus.  None of the MOLLE gear and self-absorbed incident command classes are worth much in this.  Except for one aspect of incident command — namely logistics.

Second, we’ve once again learned that EMS has little surge capability. I’ve discussed this before. And most EMS (and fire) services that have transitioned from being rural/suburban combination organizations to small paid departments claim they can rely on mutual aid.  That’s well and good until EVERY system is facing the same demands. Then, you’re waiting for the state and federally contracted providers to deploy within the week.  Maintaining a part-time and/or volunteer program helps relieve some of the stress on the system.

Next, if there’s one key lesson to be learned from this pandemic, it’s that EMS needs better personal protective equipment (PPE) and infection control practices above and beyond parroting the buzzword “BSI.”

In that light, I’d hope that after this, every EMS system makes appropriate PPE available. And that needs to include changes of uniform. (I’ve lost count of how many EMS services think that the part time guy only needs one uniform shirt and nothing else.)

My recommendation for after this is to have an adequate supply of surgical and N95 masks on each rig along with appropriate cleaning supplies. Everyone should get at least 2 complete changes of uniform. Ideally, there should be a couple of pairs of scrubs on board the ambulance/response vehicle in the event you have to decontaminate before returning to the station.

I’d surmise that many of the logistics problems EMS faces stem from two things.  Number one, we stink at public outreach and education.  Most people don’t even think about EMS.  Second. we’re not sure if we’re healthcare or public safety.  That makes it harder for us to access those things reserved specifically for healthcare — or traditionally provided to healthcare organizations.  It took advocacy from the American Ambulance Association to make Amazon’s healthcare specific “store” open to EMS organizations. And at least anecdotally, the public health bureaucracy which administers the majority of the pandemic response often forgets about the needs of EMS. In fact, I’m not unfamiliar with disaster response from both my career in state government as well as my EMS work — and I’m still not sure what, if anything, EMS is getting from the Strategic National Stockpile.

What would I like to see happen?  I’d like to see proper preparation for the next time, because there will be one.  And I’d like to see adequate supplies of both equipment and personnel.  But being an attorney with experience in government, I’m a realist.  And considering this experience. I am cynical enough to have a good guess of what will happen. There will be a massive initial push to get all of this done. There may even be Federal grant money to make this happen. 99.9% of the Federal grant money will be awarded to departments that don’t really need the money. 99.9% of said awarded equipment will dry rot and expire in a warehouse. Some TV newscast will run a story on “a storeroom full of stuff that no one uses” and the stuff will be surplused. Then when COVID-2023 makes its debut, we’ll be right back at square one.

The other thing my cynicism has convinced me of is that the majority of the funds made available for the next pandemic will go to the various public health bureaucracies, certain hospital networks, and the politically connected fire services.  Why?  Because those are the people with the political savvy to navigate the legislative, bureaucratic, and grant processes.

Rural EMS and the Rural Hospital Crisis.

One of the best pieces of advice that an attorney gave me as I entered the legal profession was that I should read the news every day.  He told me that you never know what future cases might be in the news.  Being a bit of a nerd for politics and policy, I still follow that advice.  This morning’s review of the news led me down a trail where I ended up reading an article from a liberal/progressive publication about rural hospitals in Texas closing.

The article had two accounts of patients dying because a rural hospital in northeast Texas had closed. One patient apparently had a heart attack and the other patient had a brain aneurysm. And the article quoted family members and local politicians as saying that these people wouldn’t have died if the little hospital had still been there.

If you’ve got any experience (or even baseline knowledge) of emergency medicine and EMS in particular, you’ll know that rural hospitals have limited capabilities.  In fact, both of the cases in question likely could  not have been stabilized at a local rural hospital. Both of these patients required extensive specialist interventions that would typically be found in a larger city.  In fact, taking these patients to a rural hospital without specialist capabilities would have actually delayed care.  The well-intentioned laws designed to prevent dumping of patients into an emergency department (EMTALA) would have required the initial hospital to find a specialist facility to accept this patient and then transfer care to said facility. Even in other cases, patients admitted to a hospital may require specialist care or intensive care treatment that is largely unavailable in rural hospitals.

A properly trained, staffed, and equipped EMS system would have been able to recognize that these patients required care well above and beyond local capabilities.  Properly trained and equipped paramedics would be able to provide the same resuscitation and stabilization abilities AND transport directly to the appropriate specialist facility.  As I’ve heard said more than once, there’s no magic resuscitation fairy waiting at the hospital.  Resuscitation measures are the same, whether in an inpatient setting or out of hospital.

The solution to healthcare in rural America is not to engage in a quixotic quest to reopen rural hospitals with limited capabilities and delaying access to definitive, specialist care.  The solution is to channel that funding toward expanded access to primary care, specialists making regular visits to rural communities, and establishing a robust EMS system that provides comprehensive and competent paramedic level care. With an aging population that’s poorer than average, a strong EMS system can absolutely make a difference in rural healthcare. And our EMS voices need to say such.  We are the experts on emergency care outside the hospital.  Period.

Journalists know how to write.  They rarely know medicine.  Or policy.  In this case, their advocacy may well harm patients by delaying definitive care in favor of local care.

Election Night (Not what you think)

Election Night brings out the worst in many of us. In large part because of the 24 hour news cycle amplified by social media, we get way too invested in politics and sometimes let our mouth overload our rear. (Pro-tip for those of us who love politics and love discussing it, private groups are the way to go on Facebook.)

I saw some of the worst behavior come from my fellow members of the Bar. Many attorneys I know were posting things that I wouldn’t have expected from dispassionate professionals.  The comments (and they were from both sides of the political aisle) ranged from sour grapes, veiled passive-aggressive statements, or out and out statements that they’d be unfriending people. (Another pro-tip here.  I do know some of these people and it speaks volumes as to their professionalism and whether I might believe they have the temperament to handle a case I might refer their way.)

Late last night, a post started making its way through EMS social media showing a paramedic saying (in part), “I’ll start asking if you are a trump (sic) supporter – if you are, y’all will die in my ambulance.”  The response from EMS was swift and gave me a great deal of hope for our emerging profession.  Everyone denounced it.  Whether you wanted to “make America great again” or identified as a democratic socialist, everyone agreed that this sentiment had no place in EMS.  And they spoke up.  Not only did they speak up, they made a point to notify this guy’s employer and the various licensing entities that they didn’t want him in our profession.  At least one employer terminated their relationship with him by morning and at least one licensing agency is aware of his temperament to practice as a paramedic.

Regardless of whether the gentleman deserves to remain employed or certified as a paramedic, our profession spoke with one voice and said that we won’t tolerate such a mindset. And my other profession, the profession of law, has become so politicized and activist (on both sides) that we have, at least in some part, lost track of what we’re supposed to be doing, namely zealously representing our clients and providing them with sober counsel.

Last night, EMS stepped up and took a stand for our profession.  And for a change, we did it better than the lawyers.  Pardon me while I brag on being a paramedic. We’ve beat the other professionals at being professional and separating the personal from the professional.

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.

Are You Really Surprised?

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

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

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

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

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

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

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

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

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

Google Let Me Down.

The following is an email that I sent to Google in response to them choosing artist/activist Yuri Kochiyama for today’s Google Doodle on the main Google page.

I realize that Google Doodles are sometimes meant to cause us to think.  That’s a good thing.   But today’s Google Doodle honoring Yuri Kochiyama was way too much.  I “Googled” her and found this in Wikipedia:

In response to the United States’ actions following the September 11 attacks in 2001, Kochiyama stated that “it’s important we all understand that the main terrorist and the main enemy of the world’s people is the U.S. government” and that “the goal of the war [on terrorism] is more than just getting oil and fuel. The United States is intent on taking over the world.”

While the United States has certainly made mistakes and there are certainly different views about our role in the world, I consider honoring this “activist” to be a grave dishonor and a slap in the face to those who died on 9/11, first responders, and those who serve in our United States armed forces.

Over the last two weeks, there has been extensive media coverage about an anti-conservative bias in the tech world. While I had been somewhat skeptical of this, your decision to “honor” this far-left, anti-American activist is certainly evidence of at least a cognitive disconnect with many Americans, especially those who hold conservative or libertarian values.

To me, Google is a source of information.  I expect an information source to be an honest broker of such information or, at the very least, to disclose its biases.  Today, Google let me down.  And that’s something that’s let me down.

Very truly yours,

Wes Ogilvie

I could go on and on here, but suffice it to say that I think it’s bad business to take an unnecessary political stand that pokes many of your customers right in the eye. Rather than an attempt to be hip, edgy, or thought-provoking, this decision shows the disdain that many in the cultural left have for anyone in “flyover country.” These tech hipsters share their progressive views where the tech industry gets government subsidies while wearing a Che Guevara t-shirt and “Feeling the Bern.” It always strikes me that many of the people who are the loudest about the wrongs in America are among those who benefit the most from what makes America great — namely free enterprise supported by the values enshrined in our United States Constitution.

In summation, you’d never have a Google, Apple, Facebook, Dell, the New York Times, or even the movie industry in anyplace but America.  And as the late great Merle Haggard sang, “If you don’t love it, leave it.  Let this song I’m singing be your warning.”

This is a collaborative post by Too Old To Work, Too Young To Retire (TOTWTYTR) and me. It started from an email exchange and then we decided write a post that will appear on both blogs. I’m not sure exactly how this will work out, but it’s worth a try.
TOTWTYTR: I will say that I’m not sure how much Presidential election blogging I will do this time around. Neither of the “presumptive” candidates are ideal by any definition of the word. One is a brash entrepreneur and reality TV show host with no political experience. The other is the epitome of the political insider. Who also happens to have little in the way of achievement that isn’t tied to her former President husband. Trump is (or was) hated by the GOP establishment, while Clinton is the darling of the Donkey set.
Those are my preliminary thoughts outside of the collaborative portion of the post. The parts in regular fonts are from the original email from The Ambulance Chaser. My comments are in red interspersed.
ME: So, since we’re among friends and for the most part, relatively like-minded
ones at that, I figure I’ll share my insights as to how we’ve ended up with
Donald Trump as the presumptive Republican nominee.
Let me first say that, in the words of Marc Antony, I come to bury Trump,
not praise him.  I cast my vote for Cruz not out of support
of him, but at least knowing who he is and what he stands for.   Like some
of us here, I too share the disgust at the Republican Party’s current
fascination with bedroom and bathroom habits.  It’s unseemly,
narrow-minded, and especially hypocritical coming from a party that
supposedly is the champion of limited government.
TOTWTYTR: Which is the common perception, but the Democrats seem far more interested of
late in peoples’ sex lives and bathroom habits. After all, it’s they that are proposing “affirmative consent” laws
on campuses and trying to change the public bathroom habits of the American public.
Trump has for the most part totally ignored those issues and the pressure to discuss them. Wise move.
My major complaint with the Republican Party, which I share with you, is that they aren’t acting like conservatives.
This despite the fact that most Americans are politically center-right, not left.
ME: So, how’d we get to Trump?  Well, for one thing, I do think that social
conservatism has a limited appeal.  There’s only so many voters out there
for whom homosexuality, abortion, and school prayer are their core,
fundamental issues.  Bluntly, if it was me, I wouldn’t even make an effort
to appeal to them.  And by and large, Trump really hasn’t.
TOTWTYTR: See? We agree.
ME: What has Trump done?  He’s appealed to blue collar Reagan Democrats.  The
comments about foreign trade and “making America great again” appeal to
blue collar, Rust Belt voters.  For all of the talk about the Republicans
being “politically incorrect,” the Republicans really aren’t all that
willing to offend or speak painful truths.  Trump has said what many people
are afraid to say in “polite company” about immigration and Islamic
terrorism. And in that “everyman” appeal, he scores more points with
voters.  While I don’t have the statistical analysis, I’d hazard a guess
that Trump is doing especially well with independent and previously
unengaged voters.
TOTWTYTR: This is one point on which we disagree.
Trump is drawing support from broad segments of the population. For the
most part it’s people who are fed up with the establishments of both
parties. That was part of the appeal of Ted Cruz and is a large part of
the appeal of Bernie Sanders.
My sister, who is at least on the surface a liberal Democrat, is a self
described “Bernie Girl”. I’m not sure what his appeal to her is, because
chances are she’ll be negatively impacted by his communist financial
policies.
My son has a MBA and is a Trump supporter. Trump is hugely popular in
the southern state in which he lives. My daughter in law says that if it comes
down to Trump vs Hillary, she’ll stay home. Which is okay, because
that’s in effect a vote for Trump. She is pretty conservative. No
college, but she’s a sharp young women.
Mrs. EMS Artifact didn’t like Cruz, but likes Trump. If anything, she is far more
conservative than people think I am. She can’t stand Hillary or Bernie, especially Hillary.
My friend Peg, a former Canadian and former left leaning Democrat, hates
Obama, Hillary, and Bernie. She likes Trump, but not Cruz.
Women not liking Cruz seems to be a trend, at least in my not very scientific polling.
I have several friends who are life long Republicans who like Trump.
They’re tired of the GOP establishment bending over for the Democrats.
They want conservative fiscal policies, don’t care about social issues either way, do care about immigration.
I could go on and on in this vein, but I think the point is clear.
ME: In all fairness, Trump is remarkably naive on foreign and defense affairs.
His comments about making NATO, South Korea, and Japan pay for more of
their defense are short-sighted and, if enacted, could well lead to the USA
losing leverage there and those nations asserting a more independent
foreign policy that might not align with US interests.  As for his domestic
policies, he makes vague promises that make for great soundbites.  For
those that mock and dismiss him, I’ll note that Obama got elected on vague
promises of “hope and change.” That worked for enough voters.  It might
just well for Trump.
TOTWTYTR: I don’t know if Trump is a conservative or not. I think he’s more of a
populist than anything else. If he wins, I hop he’ll make good choices
for his cabinet, national security adviser, head of the CIA, etc… The
big question with Trump is federal judges, especially SCOTUS.
This is my biggest question mark about Trump. What will he do if he wins? Will he govern from the center,
the right, or the left? Or a mix?
Of course he won’t be the first candidate that was elected with the electorate not knowing where he
stands on some crucial issues.
Of course, I could be wrong about that. He might pick judges that are more liberal than would Hillary.
I doubt it, though.
Obama has proposed that our allies pick up more
of the funding for NATO and their own defense. Which is one reason we
don’t have nearly as many allies as we did a few years ago.
Japan has increased defense spending, as have other of our allies. They have
zero faith in Obama fulfilling any of the US obligations to defend them if it
comes to that. T: aiwan and South Korea share that, as do allied countries in Europe.
Our so called allies in the Middle East are also very concerned about this election.
I’m not suggesting that we pay for all of our allies defense forces, but there is value
in having a strong military of our own. Helping other nations is part of that, but they are going
to have to increase their commitment to defending themselves. Especially Europe, which I expect
is once again going to be defending the gates of Vienna from the Islamic hoards. Or maybe London,
Paris and Berlin.
ME: Both parties are to blame for the Trump phenomenon. The Republicans talk a tough game,
especially on immigration, and routinely fail to deliver — primarily because many of
their large business supporters depend on immigration. All the Republicans have delivered
during the Obama administration, with congressional majorities for six of eight years, are
press releases, showboating, grandstanding, and pandering to a small fringe of evangelical
voters who wouldn’t vote for the Democrats anyway. The Democrats have delivered more government
entitlements, more wealth transfer, a near Communist fascination with class envy, and a naked,
brazen attempt to appeal to every identity group out there.
TOTWTYTR: Trump is expressing the disgust of people in both parties with the
status quo. You’ll notice that no one has asked Obama to go out and
campaign with or for them. For good reason, President Jug Ears is not
particularly popular.
ME: The media?  Well, they have some fault too. They bemoan the lack of
substance in politics, yet they engage in “gotcha” journalism designed to
dig up past mistakes and foibles, thus eliminating anyone except those
bland candidates who, since fifth grade, have strove to avoid anything
controversial or embarrassing.  They’ve turned politics into a horserace
and a reality show.  In fact, “Who Wants To Be President” might well turn
out a better candidate than the primary process has this year.
The media is in the bag for the Democrats. Very few people in the media
identify as Republicans and even a casual perusal of the news will show
that the main stream media does all it can to cover for Obama and
Hillary. I expect that the attacks on Trump in the MSM will intensify
now that he’s the presumptive nominee.
The modern left and the modern right are both incredibly out of touch with
most Americans.  Both parties engage in “crony capitalism” where free
enterprise is a myth.  Rather, big business plays both parties for
subsidies.  The Republicans fund “economic development” and grant subsidies
to corporate agriculture.  Meanwhile the Democrats will fund “green energy”
and want to address economic justice by giving money to people with bad
credit and build nice things in areas where people are rioting.
So, when modern liberalism helps us “feel the Bern” in our “safe spaces”
and modern conservatism is worried about the bathroom at Target, yet fails
to seriously address terrorism or an economy that works for what the modern
left and the Wall Street crowd calls “flyover country,” we can look in the
mirror and realize that the sad state of American politics and the American
media have given us Donald Trump.  We’ve ended up with a self-funded
billionaire who, by his sheer wealth, is perceived to not have to pander to
any donors and says the first thing on his mind.  America, meet your
reality show presidential candidate.
TOTWTYTR: Thus, we have the rise of a neo populist candidate that has been remarkably non specific
about what he actually plans to do to “Make America Great Again”.
Obama gave rise to Trump’s model of campaigning. He too ran as a neo populist who was remarkably
non specific about what he would actually do. We’ve had eight years of fundamental transformation and
it appears that much of the voting public is tired of that.
I’m not sure if the public knows that they want in the next President, but they have made it very clear what they
DON’T want.

https://theambulancechaser.com/2016/05/489/

You Get What You Pay For

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

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

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

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

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

Clickbait for you. Frustration for me.

Right now, the EMS social media is abuzz with a piece of so-called religious rights legislation that’s passed the Michigan House of Representatives.  In short, the legislation allows for a person to claim a religious exemption from other laws that infringe upon their religious rights.  Currently, legislation such as this is most commonly championed by Christian social conservatives as an attempt to nullify local and state gay rights provisions.  Our “friends” at EMS1 are headlining this as “Will Michigan allow EMS providers to withhold care based on the patient’s sexuality?”

Here’s my take as an EMS provider, attorney, and someone who’s analyzed state legislation for over a dozen years.  Oh, and also as someone who completely supports the rights of gays and lesbians, including the right to marry.  This bill doesn’t impact EMS one bit.  Not one iota at all.  Doesn’t even mention EMS. I am not YOUR lawyer (although, for the right retainer and hourly rate, that COULD change…), but I can’t see how this proposed piece of legislation changes the duty to respond and the duty to act for EMS (or the fire department or police either).

Also, the bill has only passed through the Michigan House of Representatives and still has to make it past the Michigan Senate and get the signature of the Governor.  As I’ve said before, the legislative process is designed to kill legislation, not pass it.  The chances of a bill getting becoming law are slightly better than my getting a lucrative basketball contract, but probably not as good as your next EMS shift not getting to transport a non-acute patient.

I blame two parties for this kerfuffle and misinformation.  One, somewhere out there, there’s probably a well-meaning and sincere gay rights activist who took the conclusions of this legislation well past the logical extreme.  Second, the lemmings of EMS social media AND the EMS websites blindly posted this without any research, whether out of a lack of legal understanding, believing in a specific agenda, or just trying to drive up clicks.

I’m going to do something I only do occasionally and only when I’m really peeved. I’m calling a publication out by name.  EMS1 — You guys should know better.

As the great American President Abraham Lincoln once said, “Don’t believe everything you read on the internet.”