We Need More Lawyers

Shakespeare wrote in Henry VI, “The first thing we do, let’s kill all the lawyers.” Even as a practicing attorney, I can empathize.  As I like to say, ninety-nine percent of attorneys give the rest of us a bad name.  Or there’s my other favorite attorney joke, “What do attorneys use for birth control?  Their personalities.” But joking aside, the Shakespeare quote is often misinterpreted. In fact, many have argued that the villain in Henry VI proposed killing all the lawyers because they ensure the rule of law exists, that is a fair system where people understand the rules and are held accountable to follow said rules. In other words, we need lawyers for the system to work.  And I’d submit to you that one of the reasons why the EMS system isn’t working is precisely because we need more lawyers.

As I stated above, lawyers make sure the rules are understood and followed.  All too often in EMS, that doesn’t happen.  In EMS, people make arbitrary decisions that are rarely applied fairly, much less with an understanding of the law.  In the National Registry testing and renewal process, I’ve heard and witnessed stories of various EMS functionaries refusing to sign renewal paperwork, all without giving an explanation of why.  The National Registry even has a process for a former paramedic to recertify provided certain conditions are met, including obtaining the signature of your state’s EMS director.  In Texas, a previous state EMS director refused to engage in this process based on the vague claim that he did not believe he had “authority” to sign the document.  Again, an EMS provider harmed by an arbitrary and probably incorrect view of the law.

Another example of EMS arbitrariness routinely comes up with state licensing laws, particularly relating to reciprocity, the process of moving your certification from one state to another.  More than one state has laws and regulations requiring state residency and/or employment prior to granting reciprocity. The problem is that such a requirement appears to fly in the face of legal precedent established by the United States Supreme Court in the case Supreme Court of New Hampshire v. Piper, 470 U.S. 274 (1985).  In the Piper case, the Supreme Court found that a New Hampshire state law requiring one to be a resident of their state before being admitted to practice law was unconstitutional.  The parallel to several states requiring state residency and/or employment for EMS reciprocity is striking, yet EMS continues to ignore it, either from sheer ignorance or perhaps believing that EMS is “special enough” that a Supreme Court case might not apply to it.

Much of my day as an attorney is spent counseling clients on what the law means, how it applies, and how we can use the law to mitigate risks. In EMS, we routinely seem unwilling to seek such guidance, preferring instead to rely on “we already know what a lawyer is going to tell us.” We see this all the time with policies. The classic examples in EMS often seem to revolve around HIPAA. People routinely use HIPAA as an excuse for failing to get patient follow-up or why EMS can’t see transfer paperwork.  EMS managers routinely sign contracts and make personnel decisions without the benefit of legal counsel and may end up subjecting themselves and/or their employers to liability as a result.

Even with education, EMS “leaders” are often unaware of the regulatory and legal hurdles that may exist with the current push toward EMS degrees. Namely, most of the accrediting organizations that accredit colleges and universities require that college faculty possess a terminal degree in their academic field. This oversight may, again, be an example of EMS “leaders” not seeking the counsel they need.

Finally, EMS needs lawyers to keep our profession honest and to uphold standards. The latest viral video on EMS social media is of two South Carolina EMTs appearing to refuse to treat or care for a patient lacking the adequate mental capacity to make a decision. At some point, a lawyer needed to be involved, whether in the initial EMS education process to teach actual medical-legal concepts as opposed to myths and urban legends, providing legal advice as to capacity and refusals, or in the aftermath of liability or licensure.

I’ve had very little overlap between my legal career and my volunteer work in EMS.  (Having said that, if you have the ideal position that combines both, I’m open to discuss…) However, for EMS to grow and develop as a profession, we need more lawyers, not less.  EMS needs the protection that lawyers provide, both from risks outside the profession and in many cases, from ourselves.

Community Paramedicine

Years ago, I attended a Citizen’s Police Academy program sponsored by my local police department.  It was designed to give the general public an insight into how the police department works and foster communications between the police and the public.  (And for what it’s worth, EMS is massively behind the times on our public outreach.  Fort Worth MedStar is the only non fire-based EMS system I’m aware of that operates a citizen’s academy for EMS.)

One of the best things that I got from this program was an explanation of community policing. The officers presenting this material explained that the police might have an idea of the community’s needs, but without actually engaging with the community and determining what the community wanted, there wasn’t community policing. The example was that the police might assume that the community wanted something done about an uptick in car burglaries, but the community might not even know about this and might well be more concerned with people speeding through a school zone. In other words, the police figured out that community policing doesn’t work without community engagement.

And now, let’s flip the conversation to EMS. EMS is talking a lot about “change” to meet call volume and demand.  We’re talking about alternative destinations for patients.  We’re talking about triage and different response models for “non-emergent” calls. But more than anything, we’re bandying about buzzwords and have convinced ourselves that the public is “abusing” the EMS system. We’ve almost become the police in the “bad old days” of policing where the cops were “us” and the public was “them.”

In other words, we’re doing what the police did before the community policing model developed.  We’re developing an EMS system based on what we think the public wants.  Perhaps we might even be developing an EMS system based upon what EMS wants. What we’re not doing is engaging the public to determine what they want, need, and expect from their EMS system.  Absolutely, we have a professional obligation as medical providers to first do no harm. That responsibility has some obligations.  As does the responsibility to be responsible stewards of the money provided to the EMS system.

But outside these obligations, how many EMS systems or political leaders engage the public to find out what they want or expect from their EMS system?  How many EMS systems educate the public what EMS is or does beyond “call 911 for an emergency?”  How many EMS systems teach that there haven’t been mere ambulance drivers for decades — or that EMT and paramedic aren’t necessarily interchangeable terms? And have we asked the public if they want mobile integrated health?  Or if they judge an EMS system by cardiac arrest survival rates and response time?  My strong guess is that many member of our public would be very happy with their EMS system if the medics showed up on time, were nice, gave them a safe ride to the hospital, and just maybe everyone’s medical records were synced together.

But if we don’t ask the public what they want from us and how we can help, we’re doomed to irrelevance and distrust, just like the police were — before they engaged the community.

A Farewell to the NAEMT

Dear Mr. Zavadsky: First of all, I appreciate your offer to reach out last week after my blog entry regarding my views on what appeared to be NAEMT’s no position of a position statement on the ongoing discussion regarding a degree requirement for … [Continue reading]

Lead, Follow, or Get the Hell Out of the Way

If you've been following any EMS news as of late, you've read about the position paper that paramedics should have a minimum of a two year degree. The position paper was issued by the National Association of EMS Educators, the National EMS Management … [Continue reading]

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 … [Continue reading]

KISS: Keep It Simple Stupid

When you're involved with EMS social media, you see a lot of stuff scrolling through.  Some of it, like FOAMfrat, does a great job of making advanced life support and critical care concepts easy to understand. Someone much smarter than me said "Smart … [Continue reading]

Another Volunteer Crisis

As sure as the day is long, we can count on the EMS news sites to do a post on the volunteer crisis in fire and EMS organizations. And EMS1 did its part yesterday. And of course, y'all know I have to comment.  So, let's do a rehash and … [Continue reading]

More on the Four Year EMS Degree

So, I'm thinking more about the push for an EMS degree. In theory, I think it's a great idea. But here's a couple of observations.   The "other countries have it" argument. Those other countries also have a national healthcare system where EMS is … [Continue reading]

On The EMS Degree

So, because of a prominent fire chief's article against EMS degrees, all of the usual EMS advocates are coming out for a gradual phase-in of a degree requirement. And it stands to reason that the fire service wants a low entry standard for EMS.  Most … [Continue reading]

Where To Fix EMS

We all know the problems with EMS.  Mostly they revolve around low pay, low standards, and unreliable sources of funding.  Easily fixed, right?  Well, maybe. But there's an ongoing problem in EMS. Most EMS systems operate under the belief that … [Continue reading]