And So It Goes

Years ago, my friend Mike Levy used to close out his email blasts on local politics with “and so it goes,” implying his despair that things would change or improve.  This morning, I happened to see an EMS colleague post a cartoon about how everyone wants change, yet no one seems willing to change.  Below are my thoughts on where we’re at in EMS.

 

We hear a bunch of people say we need the next generation of EMS leaders step up. Then we step up and we’re told to wait our turn, bide our time, and not speak until spoken to. Meanwhile, the people who created the problems of modern EMS are on all of the blue ribbon committees and consulting teams to fix the problems they created in the first place. Tact prevents me from naming names, but if you’ve been around EMS for more than fifteen minutes, you’ll recognize the names of what Mad Magazine called the “usual gang of idiots.”

And of course, as is the trend in modern politics, EMS continues looking for the single solution that will fix all that ails EMS.  A few years ago, it was community paramedicine.  (By the way, yours truly still thinks that knowing how to navigate the healthcare and social services systems and pointing patients to the right resources is an essential skill for a medical provider of any sort.)  Now, the latest push for EMS success has been distilled into a single catchphrase: “EMS Needs Degrees.”  It may not be as catchy as Bernie Sanders’ catchphrase of “Medicare For All,” but it’s equally simplistic and just as poorly thought out. Almost no one in EMS has thought out how a degree requirement would work, what such a degree would contain, or even found out if the higher education system(s) have the ability or desire to take on the task of educating paramedics. (Hint: Part of the nursing shortage relates directly to a shortage of qualified nursing faculty.  Considering how few in EMS already have EMS specific degrees, I can’t help but think that the shortage of qualified faculty to teach paramedics at the college level will be even worse.) And now, we have the first state proposing an actual degree requirement for EMS, namely North Carolina, which will require an associate of applied science in EMS to obtain paramedic licensure.  For many people and in many situations, this degree will be the end of their higher education journey, at least in part because the AAS curriculum rarely transitions well to bachelor’s degree requirements.  Once again, EMS looks for an easy fix to a complex problem.  As I like to say, good public policy can rarely be distilled to a meme or fit in a single Tweet.

The issues with EMS are complex and heavily tied to public policy, namely how the Federal government’s two financing mechanisms, Medicare and Medicaid, pay EMS as a transportation service as opposed providing healthcare.  That also explains why the historical option for EMS care is to offer a ride to the hospital emergency department.  But right now, instead of recognizing the need for future EMS leaders to have some concept of management, finance, politics, and public policy, we’re confining what constitutes EMS education to a set of technical skills. (I truly think that some of the loudest voices on EMS social media advocating for a degree are basing what an EMS degree should be on a wish list of skills and technology they’d like for an ambulance.  I’d also note that’s not how most educational models work aside from trade or vocational school.) We are not even guaranteeing that EMS providers are educated in the arts and sciences to understand the hows and whys of medicine and the context in which prehospital medicine fits into everything else.  And going back to my earlier comment about the current crop of so-called EMS leaders not wanting to relinquish their positions — you couldn’t think of a better way to keep the “new kids” out of leadership than to deny them the actual skill set and education they need while claiming that you’re helping the profession advance.

And so it goes.  Indeed.

Quit Operating and Start Treating

It’s time for another one of my trademarked and patented rants on what’s wrong with EMS.  And to keep with the social media crowd, I’ve been triggered.

This afternoon, I received an email from a large, national EMS conference (cough, EMS World Expo, cough) promoting a “Complex Coordinated Terrorist Attack Workshop.” The add-on course, at an added expense of course, includes managing an active shooter incident combined with a hazmat/explosive scenario.  On a similar note, an EMS organization in my neck of the woods is working on a mass casualty scenario involving hostages, improvised explosive devices, and a firefighter down — all in one scenario that’s expected to span an entire day of training.

Right now, “tactical” and “terrorism” sell seats, especially for paid training.  I get that.  I also get that we need to train for events that are unlikely to occur, but have high risk if they do occur.  But for love of Pete, can we stop already with doing training just because it sounds sexy or cool?

If we’re going to train on a mass casualty, how about training on something that’s actually likely to occur in most EMS organizations’ service areas?  A MCI involving a school bus is much more likely to happen than a dirty bomb or an active shooter.  And if you factor in getting the right patients to the right hospitals, the logistics of parental involvement, or even factoring in road closures, this MCI becomes a real (and realistic) challenge.  Besides, if we’re truly following the National Incident Management System and the Incident Command System models as required by FEMA, the type of incident shouldn’t matter.  NIMS and ICS are what we should be using for command and control of any emergency incident.

Meanwhile, EMS providers can’t perform a basic assessment or master the skills associated with their certification level, let alone understand pathophysiology or pharmacology. And we have raised a whole generation of providers who think claims of PTSD and burnout are what constitutes experience.

I get that conferences need to sell to the masses if they’re to remain a going concern. I also know that we’ve got a bigger problem with our profession (or what passes for it) and our personal standards if this is who we’re marketing for. While we have people getting excited over this stuff, we still have all levels of providers clinging to dogma.  We have people still putting patients on backboards.  We have supposed advanced providers thinking all respiratory ailments are treated with an albuterol inhaler.  And let’s not even talk about the people who think that “pasta water” (IE, saline) fixes hypovolemia and scoff at the notion of administering blood products outside the hospital.

Yes, there are public safety aspects to EMS.  I will NEVER deny that.  But we’re also engaged in the clinical practice of medicine.  We need to quit playing at being “operators” and start actually being clinicians.

And truth be told, I know a few actual “operators” in the field of prehospital medicine.  The overwhelming majority of them rarely talk about being operators. They do talk about the medicine — all the time.

Finally, if we think that some more “tacti-cool” scenarios are what’s needed to advance EMS as a profession, that alone is a statement of why EMS is where it is. Not to mention why we’re not advancing and why the salaries are so low.

Back In The Fire Service

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