Fight For $15

So, in a fit of rage, I was almost tempted to write a screed about how EMS providers don’t deserve the $15 per hour wage that fast food workers are protesting and clamoring for. My rationale was (and remains) simple.  After watching the attitudes from so many EMS providers, especially in the average online discussion, I’d be hard pressed to argue that many people in EMS deserve to be paid this much even.  Whether it’s the blind devotion to dogma (See also: Spinal motion restriction), the overinflated sense of self importance (See also: the usual t-shirt slogans about how under 200 hours of first aid training is equivalent to being a physician), or the culture that mocks education (See also: The usual claptrap about EMTs saving paramedics and/or “BLS before ALS”), it’s clear that many people in EMS are overpaid at minimum wage.

Today, though, I dug deeper into a recent EMS discussion about the priority between hemorrhage control and the classic “Airway, Breathing, Circulation” priorities that are drilled into almost every EMS provider.  I noticed that the majority of providers wanted a definite, absolute answer.  They wanted a clearcut answer.

Here’s the problem.  In any learned profession, whether it’s engineering or medicine, the answers are rarely clear.  Answers to most questions are heavily dependent on both the facts of the situation and the judgment of the professional.  As both an attorney and a paramedic, my favorite answer to any question is, “It depends.”  But too many of us in EMS want a definite answer.  We want a protocol or a flowchart to follow.  We claim that we want to be treated as professionals, but then we want someone to supply us the answers and make it easy for us.  Following the protocols or the skills sheet truly is the medical version of being a fry cook.  Congrats!  We’ve earned our $15.



Time To Call It Like I See It

In my EMS career, I’ve been very fortunate for two things.  One, I’ve had the opportunity to work for some great EMS systems.  Two, by virtue of my outside career, I don’t have to rely on EMS to make ends meet or pay the bills.  To me, that also means I have an obligation to speak my mind about EMS, especially since many of my colleagues don’t always have the luxury of being able to speak theirs.

Today is one of those days where I’m going to speak my mind and say it as loud as I can. A few moments ago, I saw a social media post from a large EMS publication.  The post was entitled “Addressing Ten Harmful Realities of Modern EMS.” Plain and simple, I’m not going to link to it.  Here’s why.  To be honest with you, this article was written by an EMS consultant who’s been involved in the EMS world for years.  The article is published by a major EMS publication.

In short, we’ve got the same usual suspects of the same usual EMS columnists, the same usual people who are on every EMS committee, the same EMS publications, and the same EMS consultants telling how to fix the problems in EMS that, in large part, they’ve helped create and/or perpetuate.  At the very least, they’ve been complicit in not addressing them for a damned long time.

The main EMS publications aren’t peer reviewed.  They consist largely of reprinting advertisements for products.  The “science” they post is largely dated and the truly progressive EMS systems (the ones that aren’t busy tooting their own horns) have been ahead of the curve established by the EMS publications for a long time.  I can guarantee the pictures that’ll be shown in the same publications every month: namely a picture of fire-medics somewhere on the East Coast of the US, wearing full bunker gear, working a “scary looking” car wreck, and putting everyone on a backboard.  It’s at the point that several of my smarter friends have nicknamed one publication “Backboard Action” and refer to many EMS publications as “backboard porn.”  And mind you, the science has been trending away from the spinal motion restriction dogma for a while. Our EMS media isn’t the “conscience of EMS.”  It’s little more than a cheerleading section for the self-promoters of EMS.

The article goes on to talk about working conditions in EMS.  My friends, this article is written by an advocate for many of the practices that have created these working conditions.  If you like poor pay and system status management where you park your ambulance in an abandoned parking lot at 3:00 AM because that’s where the computer predicts coverage is needed, then, by all means, continue listening to the same people try to fix the problems that they’ve created.

The same people who’ve brought us these working conditions are the same people who continue to limit the knowledge base and educational standards of EMS.  Whether they use the “poor volunteers” or the fire service as their excuse, they continue to keep the same low standards and low expectations guaranteed to “meet minimal standards” and keep EMS down.  If you wonder why the best and brightest leave EMS for nursing or medicine and why the barely competent become EMS managers or educators, look right at the same EMS committee members who continue to pass on the chance to improve our educational standards or knowledge base.

And let’s talk about the medicine.  Let’s talk about the science.  That gets defined by our professional committee members and celebrity EMS medical directors.  Every year, there’s a “Gathering of the Eagles” where a bunch of celebrity EMS physicians present their opinions.  The Eagles, in theory, represent the fifty largest EMS systems in the country.  Large doesn’t equal great.  Far from it.  The District of Columbia, New York City, and Los Angeles aren’t exactly renowned for their quality of prehospital care. These presentations have a strong bias toward cardiac arrest.  While cardiac arrest is, in part, what EMS was started to fight, cardiac arrests represent a small portion of EMS responses.  Cardiac arrest gets studied because “dead” or “not dead” is easy to quantify.  Let’s talk about pain management.  Let’s talk about airways.  And let’s not dumb down the medicine because you have a large system of providers and it’s “too hard” to roll out training or keep quality assurance and quality improvement on “so many medics.”

A special mention to the majority of the EMS conferences as well. I’ve spoken at several, primarily state, conferences.  I’ve been fortunate in that these people are usually willing to let me speak my mind on a variety of topics, usually related to the law in EMS.  But the national conferences seem to represent many of the problems in EMS as well.  Namely, you’ve got “EMS celebrities” presenting topics that are either “fluff” or represent science that is already so well-established that it’s borderline negligence to not already incorporate it in your practice.  When speeches entitled “A Pressure Dressing For the Soul” or “Incorporating CPAP into Your Practice” are major speeches, the problem is clear.  By making everyone feel good about themselves and their practice of medicine, you may get “butts in the seats” but you’re sure not advancing the profession.  Just once, I’d pay good money to have someone present on the Dunning-Kruger effect and its applicability to EMS. Instead, we get feel good platitudes from someone dressed in a uniform that looks like a third world dictator.

In other words, the same people doing the same things in EMS aren’t going to fix it.  But I’m optimistic.  And here’s why.  New people in EMS are stepping up to the plate.  They’re recognizing the challenges in EMS.  And they’re advancing them, even when the usual gang of idiots tell them it’s pointless.  In 2014, two medics, who happen to be friends and inspirations to me, decided that EMS provider suicides were unacceptable.  They formed the Code Green Campaign.  Several other medics I know also decided to tackle mental health in EMS as well.  They formed Reviving Responders. And in 2015, when the Texas Legislature faced opposition from emergency nurses about allowing paramedics to function in the hospital, several Texas medics started talking on social media, shared the news, and formed the Association of Texas EMS Professionals to advocate for Texas EMS in the political arena.  The issue is not whether EMS can improve.  It clearly can.  It’s just time for us to recognize that what Mad Magazine calls “the usual gang of idiots” aren’t going to get us there.

To the younger EMS providers, I say, this is your time.  Stand up and lead EMS because the dinosaurs have failed to evolve and are doomed to extinction.  There is ZERO reason why EMS can’t become a respected medical profession entrusted to perform advanced assessments and interventions in the prehospital setting.  The only thing preventing this is that we’ve selected the wrong leaders.  Probably more accurately, we’ve been passive and allowed the wrong people to claim to speak for EMS.

Thank you for reading and for allowing me to be a voice out there.

So, You Want To Be An EMS Writer?

Everyone wants fame and notoriety.  Some even find it. A few find fortune with that fame. I may not be able to promise fortune, but I can sure tell you the keys to becoming famous by writing another EMS social media clickbait posting. If you just follow my simple steps, you too can be internet famous!

First, you need to say something controversial. Next, throw in some data, preferably about cardiac arrest survival.  Add one glowing reference to some current EMS fad, perhaps community paramedicine or bystander Narcan. You will get bonus points for mentioning a “respected” EMS organization.  Instant credibility will be awarded for mentioning Seattle or King County Medic One or Wake County EMS. (Note: DC Fire/EMS does not count….)

If you’re feeling especially creative and want even more instant credibility, you should be sure to mention The Gathering Of The Eagles.  As we all know, no EMS innovation is complete without it being the subject of a speech or PowerPoint at the Eagles conference.  (In all seriousness, I would again note that the Eagles are the medical directors of some of the largest EMS systems, not necessarily the best EMS systems.)

Here’s a winning example of a great topic guaranteed to get you likes and shares on EMS social media. “EMS Community Paramedics should embark on a pilot program to train police officers and bystanders to administer Narcan in cardiac arrest to boost survival rates. We are looking forward to having Wake County EMS present on the community paramedicine aspect of this program at the next Gathering of the Eagles and King County Medic One has some very promising cardiac arrest survival rates to present as well.”

If none of this works for you, another sure-fire winner is to write about how EMS doesn’t get the respect it deserves, but also say that the educational standards are set too high.

If you get an article like this going, you’ll surely become infamous.  And just like in the movie The Three Amigos, “Infamous is when you’re MORE than famous!”


We Deserve Respect?

At every gathering of EMS providers, whether in person or in the online world, we constantly bemoan the perceived lack of respect that the “ambulance drivers” get from the rest of the medical community, from other public safety providers, and from the public that we serve.  So, to answer the question as to “when will we get the respect that we deserve,” I present the following answers.

When doing the right thing for the patient becomes more important than doing something, no matter what it is.

When we embrace education and science-based medicine rather than dogma because “our instructor said so” or “I’ve seen it work.”

When we work constantly to raise the minimum standards for entry into EMS rather than continually watering down standards while using “the volunteer crisis” as an excuse.

When we spend as much on continuing education and pursuing knowledge as we do on getting another set of LED lights for our personal vehicle.

When we embrace professional self-regulation rather than being an afterthought in most states’ health and human services bureaucracies where the same people inspecting ambulances are inspecting tattoo parlors and tanning beds.

When the term “semester” replaces “clock hours” for ALL levels of EMS education.

When we recognize that patient advocacy and customer service are part of the job rather than something to be ridiculed with a t-shirt slogan.

When we realize that completion of a 120-180 hour EMT course and passing a test of minimal competency is but the beginning rather than the pinnacle of a medical career.

When we recognize that heroism consists of significantly more than merely working in the emergency medical field and doing your job.

When punitive medicine like selecting IV catheter size based on your annoyance factor with the patient or joking about rapid sequence intubation of a patient without adequate sedation is no longer accepted on your ambulance. (At the very least, can we not make these comments in a setting where the public can hear them?)

When shop-worn slogans denigrating advanced practice in favor of “BLS before ALS” are recognized as the anti-intellectual attitudes that they are.

When EMS education reaches a point where one can become a paramedic without first having EMT certification.  Doctors didn’t go to physicians’ assistant school first and lawyers don’t have to become a paralegal first.

When we recognize that “street experience” may actually be meaningless if it was three years of working a BLS transfer truck and learning nothing but bad habits, shortcuts, dogma, and who gives free coffee to EMS.

When we realize that the most important thing that any EMS provider can do is to provide a thorough, competent assessment rather than some “sexy” skill.

When we stop using “the lawyers” as a mythical bogeyman and start understanding the laws and regulations that impact the practice of prehospital medicine.

When we as EMS providers have a voice at both the US Capitol and each and every state capitol.

When our goal is that we leave every patient at least as well as we found them.

When we stop defining EMS by “what we can do.”

When we realize that we DO diagnose and that diagnosis is not illegal, but rather, is expected.

When we recognize that what’s not an emergency to us is still the most important thing that’s happened to the patient today.

When we realize that the most important person in the room is the patient.

When we cease to define clinical competency by parroting a skills sheet.

When EMS managers cease to define success by response time and cardiac arrest survival.

When every EMS provider in every EMS system knows who their medical director is and how to reach them.

When we realize that continuing education is designed to teach new concepts rather than just merely repeating the same dogma on a two year basis.

When we recognize that lowest common denominator medicine means that providers will sink to the lowest common denominator.

When we finally realize that the biggest obstacle to EMS advancement is the average EMS provider.

When we recognize that it’s not our job to judge our patient, but it is our job to treat our patient.


When we can hit even fifty percent of these goals, the respect will be earned.  And so will the salary.

What We Really Are

I see a lot of people in EMS who want to be heroes.  I see a lot of people in EMS who consider us part of the public safety family.  Occasionally, there’s some heroism in EMS.  And yes, in many places, EMTs and paramedics are part of the public safety team. I also hear the term life-saving bounced around.  I can count on one hand the number of EMS calls where a life was immediately saved by EMS interventions.  Lives prolonged?  Yes.  Lives made better? Yes.  Lives saved immediately?  It’s a rare occasion.

I have a real concern, though.  None of those reflect the day-to-day reality of EMS.  In my opinion, after a few years in this field in a variety of settings, we rarely get to be heroes.  In fact, if we’re at the point of heroism, something’s likely to have gone really wrong in the course of the call. What we really do is deliver unscheduled out-of-hospital medicine.  Our definition of “emergency” often varies from the patient’s definition, but the God’s honest truth is that we’re here for our patients.  Period.

Over the last couple of days, I’ve been pretty dismayed by some posts I’ve seen in EMS social media groups, whether by new EMS students or experienced providers.  I’ve seen posts advocating “punitive medicine” like ammonia caps and dropping the patient’s hand on their face to determine if the patient is “faking” a seizure.  I’ve seen other posts asking how to identify “drug seeking” patients so that a provider can hold back pain relief.  I’ve seen posts advocating that EMS providers be allowed to decide who gets to go to the emergency department. And I’ve seen posts by supposedly experienced paramedics advocating “just taking the patient to the hospital” rather than performing a complete assessment and providing treatment all because the hospital is close.

I get all of these complaints.  I really do.  We’ve all been on the shift where the calls keep coming and it seems like no one really has a supposedly legitimate emergency.  I’ve complained.  I’ve griped to my colleagues. And I try not to let it impact what I’m doing as a medic.

The reality is that we may be public safety heroes who save lives — occasionally.  But what we truly always are is professional caregivers.  Part of the obligation that you have is to suspend your judgment of the patient in order to CARE for them.  Even the most malevolent, challenging psychiatric “frequent flyer” has issues that we’re not going to be able to understand, much less fix as EMS providers.  Our duty is to assess the patient, provide care as we’re educated to, and get them to an appropriate destination to address their concerns.  When we start embracing the care aspect of the job more, we’re going to have less burnout, better outcomes, and probably some happier EMS professionals.  Until that point occurs, I’m concerned — because I’m seeing what people think is acceptable.  Ask yourself if that’s how you’d want your family treated or if you’d be proud for the local news media to showcase your last call.

It’s time for all of us in EMS to take a look in the mirror and see what we’re becoming.  I, for one, am not sure that this what any of us should accept or condone.  We can do better.  I know because I’ve seen us do better.

Dear EMT Student

Early this morning, I brought my father to the ER.  He’s getting up there in years and he’s pretty sick.  You came into the room with several of the nurses.  Having remembered my ER clinicals, I slid over and introduced myself to you and told you what was going on with dad.  With his congestive heart failure acting up, I suggested that you might want to listen to his lungs.  You told me that you had “already gotten all of your lung sounds.”  Apparently, I should’ve caught onto that from the fact that you weren’t even carrying or wearing a stethoscope.  You never introduced yourself to me, my father, or anyone else in the room.  You never laid hands on the patient, did an assessment, or performed any skills.  However, I did see you spending most of the rest of the night sitting at the nurses station cutting up with the unit clerk and the techs.

Congratulations, kid!  You’ve succeeded. You’ve illustrated so much of what’s wrong with EMS.  You came to a clinical unprepared.  You showed me through both your actions and attitude that you’re merely marking time and there to get the very minimum done.  You showed a clear lack of interest in furthering your knowledge above and beyond the very minimum entry level of one of the most minimal entry level jobs in healthcare.  And most importantly, you’ve confirmed to me and probably a good chunk of the hospital staff all of the rumors about EMS and EMS students in particular.

You’ve done a great job of harming our profession.  I only have two hopes for you. One, you hopefully get with the program before you end up harming or killing someone with your obvious lack of interest in medical care. In the alternative, I hope the National Registry exam does its job in keeping out the clearly incompetent.

And by the way, for the record, you’d have never started a clinical with me as your preceptor.  Your stethoscope is a required part of your uniform at your program.  You’d have been sent home with an explanation of why; I’d have notified your education program; and I’d have told you to reschedule.

When we allow students like you to progress, all we do is continue to shortchange our profession and retard the growth of EMS.  To my fellow EMS educators, it’s time to abandon “no medic left behind” and start holding students accountable.

My Sermon to You

I’m not the world’s most religious guy.  But I just awarded myself a new title. I’ve accepted ordination as a reverend in the EMS Church of the Painful Truth.  And for my fellow followers of the gospel of the truth that EMS is the practice of medicine, I deliver to you my first sermon.

I direct my preaching at the wayward masses.  Because, after all, it’s the sinners who need salvation, not the choir.

Here’s who and what holds EMS and EMS education back.  Students who consistently fail to take responsibility for their own learning; the fictional belief that some specific study guide or app will magically allow them to pass NREMT; the belief that the NREMT exam is difficult; low entry standards for any EMS education program; and an army of mindless drones bleating along about how “you can do it.” And of course, the belief that the test shouldn’t matter so long as you can do skills and you want to be in EMS. I am fully expecting to be called a meanie, unsupportive, a paragod, and probably several other names. Here’s one thing though. I’ve achieved my EMS certification. The secret? A little bit of intelligence, some common sense, and a four letter word that’s forbidden to so many unsuccessful EMS candidates – WORK.

If EMS is that important to you and you truly feel called to deliver medicine at all hours of the day or night, then EMS should be important enough to master, much pass an entry level test designed to measure minimal competence to practice your craft safely.

No more excuses.  Join the EMS Church of the Painful Truth.  All you have to lose is your dogma and all you have to gain is the knowledge that, contrary to what the rest of our craft says, you are a medical professional.  And the Kool-Aide is safe to drink.

Medical Practice By Cliche

One of my biggest complaints in EMS education and practice is that too many providers take clichés from t-shirts and turn them into the dogma of EMS practice.

Two of these overused sayings are similar.  “BLS before ALS” and “EMTs save paramedics.”  And they’re two sayings that when the President appoints me “EMS Czar,” I will ban with the severe penalty of taking away your collection of EMS t-shirts and Galls’ catalogs.

My biggest concern is that many of the people who repeat these saying the loudest (because we all know that in EMS, loud=winning) are those who are BLS providers who don’t have ALS education.  This is the equivalent of me spouting off that paramedics save physicians, even though I only have a vague idea of what happens in medical school or graduate medical education.

The realities are this.  These cliche sayings are nothing more than feel-good t-shirt sayings designed to boost the ego of entry-level EMS providers.  Furthermore, even a marginally competent paramedic doesn’t differentiate between BLS and ALS skills and assessment.  They synthesize the knowledge they have along with their experience to create a holistic view of the patient and treat the patient as such.  In the actual world, many patients, especially those with medical complaints require the assessment of a paramedic level provider, if not paramedic level interventions.

I fully acknowledge that there are some excellent EMT-level providers out there who are the exception to my semi-rant.  These EMTs are primarily found in EMS systems where there’s an extensive field training and continuing education process that mandates a level of independent BLS practice.  In other words, becoming a truly independent BLS provider ready to assume responsibility for patient care requires much more than what currently counts for initial EMT education.

But the sad reality in much of the EMS universe is that EMT education consists of little more than showing prepackaged PowerPoints, war stories, and some level of minimal competency.  With that current paradigm, there’s only a small subset of patients who would benefit from BLS treatment without at least an assessment from a paramedic level assessment.

Ultimately, like much of medicine, and for EMS in particular, you don’t know what you don’t know.  If you want to be trusted, the best recommendation I can give is to never be satisfied with minimal competence in the entry level of emergency medicine.  Quit worrying about justifying what is really an entry level skill set — learn and grow to advance your knowledge, whether formally through a paramedic certification, or at least through formal and informal continuing education.

As most of y’all know, I tend towards blunt.  Medicine is about helping people.  And you can’t help many people, including your partner, if you merely meet minimum standards in the minimum level of certification to staff an ambulance.  And this truth remains plainly evident no matter how much you cite cliches and stories that your instructor told you.

Reality is — we’re a team.  We all have a role to play and much of the role of the BLS provider is to assist the ALS provider.

About That License

I get it.  Becoming an EMT is a big accomplishment for many, even including me years ago.  It was pretty cool to know about things and do things that the “rest of us” don’t get to do.  And the same is true if and when you make the jump to paramedic.  You might even get some neat t-shirts to flaunt that you’re an EMT or a paramedic — and especially proud of it.  The really neat part is that your state gives you a piece of paper or plastic that identifies you as an EMT or paramedic, which means you’re “officially” able to do EMS things.

I have another card in my wallet as well.  It’s my card from the State Bar of Texas that identifies me as a Texas attorney.  It means that I get to do things that others can’t do.  It’s a bit of a long road to get one of these cards.  It takes a four year undergraduate degree followed by three years of law school.  Then, the licensing exam.  It’s a two and a half day exam, given only twice a year.  And it means I get to give legal advice and represent (and counsel) clients about the law.   When you learn the law, you learn that few things are in a vacuum.  A statute alone means very little.  You need to look at the definitions that might be found in other places.  You need to look for relevant court cases applying the statute.  You need to look for regulations implementing that statute. And then you figure out how all of these things apply to the facts of your client’s case.

So, when as an EMT or paramedic with the benefit of a four hour medical legal lecture that was read by another EMT or paramedic who’s not an attorney and the slides were prepared by the textbook feels that they know the law enough to read a statute back to me and claim that’s what the law is, I do get a bit offended.  In my world, that’s the same as some attorney who’s not a paramedic hooking someone up to an IV because they saw a YouTube video.   Just like there’s more to being an EMT or paramedic than knowing how to do some random skill(s), there’s more to being an attorney than reading back a statute.  That’s why it takes a while to become a lawyer.

And that, my friends, is why I get offended when some EMT feels that they know what I know based solely on reading a statute and misinforming their colleagues.

In conclusion, I’m incredibly proud to be trusted by my state as both a paramedic and an attorney.  And I will continue to protect both of my professional identities from those who haven’t been admitted to practice in either profession.

If We’re Truly Doing Everything Doctors Do, But At 80 Miles An Hour

Look around the EMS social media world for any period of time and you’ll see a bunch of worn-out clichés.  One of the more popular ones is “We do everything a doctor does, but at 80 miles an hour.”

Ok.  I’ll accept your cliché.  And being a betting type, I’ll raise you one.  Let’s assume and accept that we, as EMS providers, are practicing medicine — because we are.  And we’re even diagnosing patients.  (Let that one sink in for a moment.  I’ll wait.)

Ok, you’re back.  So, yes, we’ve accepted the position that EMS providers are practicing medicine.  That means we’re getting a medical education as well, right?  And said medical education, regardless of how and where it’s delivered, should be at a level above high school, shouldn’t it?

You’re darned right it should be.  As I’ve mentioned in the past, for the paramedic provider, we’re trying to condense the critical parts of a bachelor’s degree, medical school, and an emergency medicine residency into, at best, a two year program.  That means there’s a lot of knowledge coming at students quickly.

Yet, of all of the education programs out there, EMS education seems to operate on the open enrollment model.  Did your check clear?  You too can try to become an EMT or a paramedic.

When we accept students who can’t express themselves in the English language, do simple mathematics, or have a rudimentary knowledge of the basic sciences of biology and chemistry, it should be little surprise that the course completion rates and National Registry exam passage rates are abysmal.  It should be little surprise that EMS students are constantly posting questions about examination and certification processes that could be discovered with a simple Google search. And it should be even less of a surprise that EMS doesn’t receive the recognition and respect that other allied health professions earn.

If we want EMS to be treated as a profession, maybe it’s time to enforce some entrance requirements.  Not everyone gets to be an astronaut or a starting NFL quarterback.  Maybe, just maybe, it’s time to say that you don’t get to play doctor in the back of an ambulance unless you have some minimum academic credentials.