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.

Brotherhood and Family

Everyone talks about the fire/EMS “brotherhood.”  Everyone says that we’re “family.”  Today, a few of my close online fire/EMS “family” were talking about how the term “brother” bothers them for some reason.

In the most abstract sense, I can get that.  “Brother” sounds like something you’d call someone in a religious order, a cult, or maybe the Moose lodge.  For some reason, I immediately picture Fred Flintstone and Barney Rubble in the Loyal Order of the Water Buffaloes.

But seriously, let’s assume that we want to be “brothers,” or to be politically correct and diverse, “brothers, sisters, and the pronoun you choose to identify with.” Well then, let’s really talk about what brotherhood and family mean in the fire/EMS world.

Brotherhood and family isn’t a t-shirt.  It’s not a cute slogan.  It’s not something we should do when it’s convenient.  It’s taking care of each other, watching out for each other, and yeah, it means we hold each other accountable too.

Brotherhood and family is checking on a partner after a rough call.

Brotherhood and family means taking the extra time to see a sick person in the hospital.

Brotherhood and family means that when you have a “brother” visiting from out of town, you spend a bit of time with them and maybe take them someplace local to get the feel of your home.

Brotherhood and family means that you take the time to mentor and train your station mates, even if both of you take time away from work to master the trade, because doing the job right matters.  Period.

One of my favorite incidents of brotherhood and family came when I did a ride at Station 11 in Clark County on the south end of the Las Vegas Strip.  As I was leaving, one of the firefighters gave me the station phone number.  I asked why.  He told me to call the station if I needed anything while I was in town because I’m “family.”

Brotherhood and family isn’t about hazing the rookies.  It’s not about creating a ridiculous paramilitary boot camp atmosphere.  And it’s sure as heck not about abusing the public trust or treating the public or our so-called “brothers” with anything less than respect.  And an IAFF sticker or a paid/volunteer status doesn’t mean a hill of beans about “brotherhood” or “family” either. It is always supposed to be about taking care of the public who implicitly trusts us to walk in their door at any hour and take care of them, hopefully like we’d take care of our family.

In other words, you can have all the slogans you want, wear all the t-shirts, say “brother” to everyone at the station, and eat all of your meals at the station’s dinner table as a “family,” but if you still have a toxic environment, inadequate leadership, a bunch of youngsters playing at being firefighters and medics, and a tolerance for inadequate service – then, no, you’re not my “brother” and you’re not my “family.”

Another Part of Being a Professional

Social media is the gift that keeps on giving for an EMS blogger.  It enables me to amplify my voice.  But today, it keeps pointing out something so obvious about why EMS still isn’t taken as a profession.

Plain and simple, part of being a professional, whether it’s nuclear engineering or being an EMT, means being responsible for your own learning. There are conferences, internet resources, journals (real journals, not trade publications), and even books that exist to expand your knowledge of all things about the delivery of prehospital medicine. Yet, there’s all too many in EMS who view social media as the equivalent of “phoning a friend” or “asking the audience” in a virtual EMS game show.  (Or maybe it’s the EMS Gong Show?)

While perusing EMS social media today, I’ve seen basic questions about how to recertify, how the National Registry exam works, and basic cardiac arrest management.  I’m far from the sharpest spoon in the drawer of EMS silverware, but I found the answers (and from reputable sources, no less) to these questions with a quick Google search. This leads me to one of several conclusions.  One, there’s a significant portion of people in EMS who are incapable of performing even basic research. Two, there are people who expect the answers spoon-fed to them.  Or three, they want someone to hold their hand and merely validate the belief they already hold.  None of these alternatives are promising for our profession’s long term viability.

As the bachelor’s degree has become the de facto standard for nursing, we continue to turn out a significant portion of so-called heroes who have no use for so-called “book learning” and believe that real learning only occurs on the “streets.”  And we wonder why the Los Angeles Fire Department is using nurse practitioners for community paramedicine?

Medicine and Politics

I get it.  Social media, outside of a few select areas, takes a fairly liberal bias.  And there’s more than a few folks who believe that being liberal is consistent with being educated.  I get that.  As a lawyer, I’m one hundred percent committed to upholding your constitutional rights to free speech, assembly, and petitioning the government.  That’s guaranteed by our Constitution, which is a pretty unique document and guarantee of your rights and liberties as an American citizen.

Here’s where I dissent.  There’s a lot of hashtag activism going on in the medical world on social media.  There’s a ton of people who’ve taken some very strong positions because they disagree with the current President of the United States.  That is well and good.  Again, it is your constitutional right.  I have two objections to this mindset.  First, there’s a bit of a violation of trust with the consumers of these clinicians’ social media feeds.  When your social media presence is that of a “Free and Open Access to Medicine” (aka FOAM) advocate, I rarely expect to see politics.  I expect to see medicine.  As both an attorney and a medical professional, I get that one may hold strong views and perhaps even consider them as part of your professional identity. I don’t expect to see a veiled insinuation (or in some cases, outright statement) that opposing the position of the United States government is part of one’s ethical obligation as a clinician. Further, I don’t expect to see the continued belief that being “educated” means you take a certain political worldview.  Perhaps we should recall and recollect about the collective clucking of tongues at physicians and pharmacists who refused to be involve with the “morning after” pill.

By all means, if you’re asked to do something unethical, stand up.  Stand up for your beliefs as well.  But using your megaphone to shout your beliefs in the ears of those who you’ve brought to your social media home to hear about medicine is, in this guy’s opinion, a violation of that trust. And that goes doubly so when the dissent doesn’t even involve the practice of medicine.

Yes, We Are A Service

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.

To The EMS Students And New Providers

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.

Charity Begins At Home

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.

Enthusiasm

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.

A Media Time-Out

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.

The Quest for Balance in EMS Social Media

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.