What Does A Paramedic Need To Know?

When I was still a relatively new paramedic, I took an EMS instructor class. My instructor had also taught my paramedic course. While I’ve forgotten a lot about drafting lesson plans (which I think may be the educational version of nursing care plans — taught in school and rarely used in practice), I do remember him emphasizing the difference between “need to know” and “nice to know” when teaching.

Yesterday, while talking to an EMS friend, they mentioned that their service does a promotional exam to promote to paramedic. (Yeah, don’t get me started on the idea that paramedic is a promotion. The idea of not using someone’s education and skills to their full potential from the get-go is short sighted, especially while there’s a paramedic shortage.) They then mentioned the extremely low pass rate on this exam. Another thing I remember from my EMS instructor coursework and many other educational settings is that a low pass rate on an exam usually reflects a problem with the education, not with the students.

Then we discussed some of the exam, which included some subtle EKG minutiae about hyperkalemia criteria. That led me to thinking about how EMS education and exams love to focus on EKG details, especially 12 leads. And once I got to thinking about that, I decided to discuss this with some of my network of EMS friends, all of whom are smarter than me. The unanimous conclusion from them was that knowing specific EKG details for hyperkalemia probably wasn’t the best test of a paramedic’s knowledge. In fact, two of them (one an experienced paramedic who’s now an ED charge nurse and the other is a paramedic who’s now an advanced practice nurse) said their expectation was that a paramedic should recognize the peaked T waves on an EKG and report their findings as hyperkalemia should be diagnosed and treated based upon lab values. (By the way, I should mention that many paramedics, including me, have a very limited understanding of lab values in large part because our education doesn’t include that.)

This then led to several of us discussing what a paramedic should know — and what an assessment of said knowledge should look like. This led to a snarky, yet accurate comment from the advanced practice nurse. They said they’d be impressed by a paramedic who does three things.

  1. Take a good history.
  2. Bring patients to the appropriate hospital.
  3. Think beyond the next hour or two of treatment.

These seem to be skills that a paramedic should master and have down but seem to be regularly lacking.

I began to wonder why this is the case and my conclusion is simple. EMS education is heavily focused on solely the “emergency” aspect of healthcare. Most of our clinical rotations are in the emergency department of a hospital or on an ambulance. Needless to say, that makes a ton of sense. The challenge is that such an educational model and mindset leads to clinicians who have tunnel vision and little, if any, understanding of the rest of medicine. And that feeds right back into those three things that would impress the advanced practice nurse (and me, for that matter.)

The question is how to fix EMS education to give students more understanding of medicine and healthcare outside of the “emergency” setting. Not only would this understanding of medicine as a whole benefit our “emergency” patients, it would benefit our less acute patients who call EMS because we are their safety net and/or in their mind is having an emergency. As anyone who’s been in EMS for more than a few minutes recognizes, our patients’ definition of emergency doesn’t always match with our education and skill set of what constitutes an emergency.

First and foremost, every EMS initial education class from EMT on up should have a lesson on how EMS fits into the healthcare system. That lesson should be expanded, especially at the paramedic level, to discuss the different specialties of medicine and the roles of other healthcare practitioners. The lesson should also include discussion of hospital capabilities. And part of the field training and orientation process for an EMS provider MUST include a thorough orientation to the local hospitals that their EMS system transports to.

One other thing. EMS clinical rotations, especially at the paramedic level, need to include exposure to other parts of medicine. In an ideal world, I’d include a rotation with a hospital based internal medicine physician to provide a better understanding of chronic and acute illnesses as well as to provide at least an exposure to the types of medical cases that are routinely admitted. (By the way, there’s study after study showing that EMS clinicians routinely lack the ability to determine which patients who present to EMS are “sick enough” to be admitted to the hospital.)

Until we get EMS to embrace the medicine part of EMS as much as we embrace the emergency part of EMS, we’re going to remain the “ambulance drivers” without a place at the healthcare table. And no amount of discussion about EMS degrees, EMS 2.0, Med Twitter, or obsessing over EKG criteria will fix that.

FirstNet Fails

Anyone who knows me well knows that, outside of my passion for volunteer EMS, I also enjoy good food and sharing my opinions about good (and bad) food with reviews.  And more than a few of you know that the job that actually pays my bills is practicing law for state government where I routinely deal with government contracts and technology.

So, now that you know all of that, you might see why I feel qualified to give a review of FirstNet, the Federal government’s wireless communications initiative for public safety and public services that’s a public-private partnership with AT&T. My experiences aren’t isolated, as I’ve seen in multiple reviews on Yelp and Google as well as stories and complaints on Reddit and AT&T’s own discussion forums.

Generally speaking, the concept of FirstNet makes sense.  The idea of a wireless communications system designed to provide nationwide coverage for first responders and public service entities is an idea worth doing.  And a partnership between the Federal government and a national telecom company is imminently logical. The Federal government has the money and resources to partner with a national telecom company to provide the infrastructure for such a network.
I’ll say this much.  FirstNet is competitively priced.  The prices for its service are significantly lower than any other option.  And unlike most other wireless providers, FirstNet doesn’t throttle speeds and allows for unlimited tethering/hotspot use.  For someone who needs to complete reports in the field like I do at times, using my cell phone to provide a wi-fi signal to my tablet is a huge deal.

But those points are virtually the only advantages to FirstNet.  For one thing, their website for billing and subscriber services is, at best, clunky. For the first responder paying for their own phone on the network, the website is illogical and hard to navigate.  My best guess is that the web access was designed to be used by those managing multiple phones for an organization.

Let’s talk about FirstNet customer service for a moment. In short, it’s non-existent. The majority of customer service and sales comes from AT&T retail outlets.  Most of these stores are remarkably unaware of FirstNet and not every employee is capable of handling a FirstNet transaction.  When I first signed up for FirstNet, I had to call several AT&T retail locations before I could find someone to help me sign up.  And even at the location that promised someone to help me, I ended up being a training exercise while a new employee tried to navigate the FirstNet signup process.  I’ll return more to customer service as I expand on my biggest concern about FirstNet.

Even before 9/11, public safety recognized that interoperable communications and communications equipment were a weakness. FirstNet was and remains one of the Federal government’s cornerstone efforts to provide seamless, interoperable communications for emergency services. So, imagine my surprise when I’ve found that phones that are supposed to be FirstNet compatible aren’t. For radio communications, P25 digital systems are largely brand agnostic.  Motorola, Harris, EF Johnson, and others make P25 radios – all to the same standards. Yet, whether by oversight or intentionally, Android phones don’t seem to work on FirstNet unless you buy a phone from AT&T. When I first switched to Android, I bought a Samsung S20+ from Samsung.  The phone was unlocked and had FirstNet’s necessary Band 14 access.  Yet, I started to have problems with my phone not working on FirstNet. I went to the nearest AT&T store and was told that my unlocked phone that I bought from the manufacturer was not FirstNet compatible.  The AT&T store personnel switched me to a regular AT&T SIM card, but kept me as a FirstNet account.  In short, I was told I’d lose some of the network priority and preemption capabilities of FirstNet, but wouldn’t notice a difference.  That was fine until I switched to a Google Pixel 6 Pro that I bought directly from Google as an unlocked phone. Bluntly, the reason that I rarely buy phones from AT&T relate to the relative unavailability of phones at AT&T retail outlets, phones that usually have less storage capacity, and the significantly better financing and pricing offers from the phone manufacturers.

When I received my Google Pixel 6 Pro, I had some problems with getting the old SIM card in.  I went to the nearest AT&T store to get an e-SIM card activated. I was then told that NEITHER of my phones were FirstNet compatible and that they couldn’t activate either phone on FirstNet.  In fact, I was told that only AT&T phones had FirstNet capability because non AT&T phones rarely had Band 14 access. The “workaround” was to sign me up for a regular AT&T account with a first responder discount.  Not only is the plan slightly more expensive, it no longer has unlimited tethering/hotspot capabilities nor does it have the network priority/preemption capabilities.

As I had bought unlocked phones, I was quite confused and concerned that neither of my IMEI numbers showed to be FirstNet compatible.  I decided to contact the FirstNet Authority, which is the Federal oversight and planning agency for the implementation and management of the FirstNet program.  I sent an email to the FirstNet Authority and began to speak with the regional representative for Texas, who definitely understood and appreciated my concerns. He assured me that I did NOT have to purchase equipment from AT&T and told me of several agencies that purchased their wireless devices from other sources and had no issues with FirstNet compatibility.  He proposed getting me in touch with AT&T’s regional FirstNet representative for the Austin area.  The AT&T regional representative had a lot of explanations at first, including that many unlocked phones aren’t meant for the US market and that AT&T couldn’t guarantee their compatibility because of missing Band 14 coverage. I then informed the AT&T representative that both my Samsung and Google phones had been purchased from the manufacturer. The AT&T representative first said that I needed to change out my new phone for the AT&T specific model number and to contact Google for that. When I reached out to Google, their technical staff told me that the phone was unlocked for all carriers and that it had an unlocked bootlogger.  I was also directed to the technical specs for the Pixel 6 Pro which showed that all models have FirstNet Band 14 capabilities.  I then recontacted the AT&T representative who said that merely having Band 14 capabilities did not mean that the phone was guaranteed to be FirstNet compatible and that my model had not been certified.  Since sending the AT&T representative the technical specs from Google, AT&T went silent for a while, then I heard from them claiming that the IMEI number is invalid.  They continue to tell me that I may need to return the phone to Google to buy a FirstNet ready phone.  And presumably, that means an AT&T purchase since an unlocked phone purchased directly from the manufacturer somehow won’t work on FirstMet.  Again, I’m pointing out that FirstNet appears to be creating a situation where AT&T is the de facto sole source of FirstNet compatible devices, at least for Android. 

Considering this, I have emailed senior leadership at the FirstNet Authority as well as the National Telecommunications and Information Administration at the Department of Commerce, which oversees the FirstNet Authority.  Again without a response.

Now, here comes my government contracts attorney side.  One of the things I’ve learned with public-private partnerships is that the private entity rightfully wants to recoup their investment. Sometimes, though, that means that the private vendor will take steps to ensure that only their product can be used.  I’ve seen that before with state contracts for services such as fingerprinting services for applicants for state licenses. What’s odd about the case with FirstNet is that AT&T seems to be implicitly requiring the use of AT&T phones (at least in the Android world) to use FirstNet. Yet, the FirstNet Authority believes that the FirstNet platform is supposed to be an open platform for compatible devices. I’m unsure exactly what has happened, but it’s clear that AT&T has been given the keys to FirstNet and the FirstNet Authority is failing to oversee the contract. Whether AT&T’s actions are intentional or accidental, the FirstNet Authority exists, in large part, to ensure that the private vendor is operating within the bounds of their agreement with the government, even more so as a recipient of public funds.

In short, FirstNet is definitely failing to live up to the expectations of being an interoperable wireless communications network for emergency services and public service.  The failings of the FirstNet Authority to oversee the actions of their contractor, AT&T, have created a situation where AT&T has been given the gift of a Federally approved monopoly to sell wireless devices to our nations first responders.

Without action from the FirstNet Authority, I believe that the next logical steps are an investigation by the Department of Commerce’s Office of the Inspector General, the Government Accounting Office, and/or Congressional inquiries.

As for my “Yelp review” of FirstNet, it’s a one star. The price is excellent, but clearly AT&T has given the first responder community this pricing at the trade-off of being bound to AT&T for devices, which are often more expensive and less capable than readily available unlocked devices sold by the manufacturer.  While I am not an antitrust lawyer, this tactic, both in terms of consumer sales and government contracting, bears investigation for potential antitrust or consumer protection claims.

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