EMS Week Thoughts

Over the last week, which happened to be EMS Week, I tried to do a Facebook post each day with my thoughts on EMS for EMS Week. Here’s that collection for y’all…

Sunday, May 16

Happy EMS Week to my EMS friends and extended family.To those of my friends who aren’t in EMS, now’s your chance to ask questions. And please, understand that EMS, EMT, and Paramedic are not interchangeable terms. EMS is Emergency Medical Services — the organizations made up of people who provide prehospital medical care. EMTs are emergency medical technicians. And paramedics represent the highest level of education and skillset in prehospital care.

Monday, May 17

I’m going to try, with no guarantees (see, there’s my lawyer side showing) to do an EMS related post every day of this EMS Week. And since a lot of people are posting about their early days in EMS, I’ll shamelessly follow that trend. In 1999, as a bored second year law student at Texas Tech, I signed up to do a ride along with Lubbock EMS because the Lubbock Police didn’t allow rides. Needless to say, after just over sixteen hours with Jackie Buck on 9744 running a cardiac arrest and a really weird car wreck, I was hooked. I pretty much became a regular around Lubbock EMS and I realize how annoying I was as someone without any training. During my return trips home and prior to getting my EMT, I also had quite a few Austin/Travis County EMS crews putting up with me. (Thanks Warren Hassinger for always answering those emails…)In 2004, I got my EMT certification and started doing things for real at CE-Bar Fire Department/Travis County ESD 10. In 2006, I decided EMT wasn’t enough and by 2007, I got my Texas licensed paramedic patch…It’s been a heck of a ride and I wouldn’t give up the experiences, education, and most importantly, the friendships, for anything. I truly have the best of both worlds practicing both law and prehospital medicine.

Tuesday, May 18

Another #EMSWeek post. I’ve been a bit of an EMS nomad over the years, having volunteered up and down the I-35 corridor of Texas as well as the Houston/Gulf Coast area and the Texas Hill Country. I have the fortunate luxury of being able to walk away from EMS because of my primary career. But if you want to know how/why I’ve been a bit of a nomad, it’s simple. I know what I’m getting paid as an EMS volunteer. Namely nothing. Zilch. Nada. Zero. What I don’t know is what I’ll have to put up with at an EMS agency. In other words, how much do I have to put up with before I decide to move on?Most in EMS don’t have that ability. But we continually lose the best and brightest to other fields, especially nursing. Maybe it’s time to look at the culture of EMS, including how we treat our fellow medics and how we develop and promote leaders. Because, let’s face it, there’s easier ways to make $15/hour than to be micromanaged while moving from parking lot to parking lot for 12+ hours at a time. If we want EMS to remain a viable career (or even become a viable career), we’ve got to treat each other better, especially our employees. Otherwise, we will never improve because we will be in a constant cycle of hiring and replacing people who’ve left the profession for something else. In some cases, people leave EMS for ANYTHING else.This EMS Week, we must do better.

Wednesday, May 19

fancy themselves influencers. More than a few of them have taken positions on social and political issues. That’s fine, although my politics usually trend differently. More than a few pride themselves on not being prejudiced. Good for them.But one form of prejudice and bigotry exists on a lot of EMS pages and groups — and seems to be tolerated, if not outright promoted. Namely, bias against one group of EMS providers — volunteers. It’s the one place where the IAFF and the “social media influencers” of EBM and third service EMS meet.These people talk about morons as volunteers, talk about how volunteers take jobs from EMS, and how there’s “not volunteers running the library, picking up the trash, or fixing the streets.” Having experienced some of the mismanagement and shenanigans in volunteer fire and EMS, including the mindset that a volunteer status is an excuse for lowered standards, I empathize.But when I remind them that I’m a volunteer, I get the answer of “you’re different.” It reminds me of the excuse “some of my friends are of XYZ group” when you call out other forms of bigotry.Is there incompetence in volunteer EMS? Absolutely. I think we all know examples — and have seen it promoted. (See also: New Jersey First Aid Council.)However, volunteer emergency services, whether EMS or fire, can — and do — work. In many of these communities served by volunteers, the only alternative would be to have a large commercial EMS operation from a nearby area pick up the community and respond from even farther away, potentially leaving the area with even more substandard coverage.Volunteer EMS has its pros and cons — just like any other model of EMS system. It can work. It does work in some areas. It’s also an abject failure in other areas, especially when the cliques and personalities override patient care and responsibilities to the community.Having said that, bias against volunteer EMS service seems to remain the last acceptable prejudice in EMS circles, particularly on social media.

Thursday, May 20

And as threatened, here’s today’s #EMSWeek post. Two words that EMS routinely fails to grasp are promotion and education. In two cases, these terms are inextricably linked.1) We absolutely stink at public education and promoting who we are and what we do. We’ve largely succeeded in educating the public to “call 911 for an emergency.” Yet, we’ve never told the public what’s an “emergency.” Anyone who’s spent time in a 911 ambulance knows that our definition of emergency and the public’s definition don’t match up. Also, we haven’t told the public much about us or what our capabilities are. See also: members of the public using the terms ambulance driver, EMS, EMT, and paramedic interchangably. See also: questions like “why is there a fire truck when I called for an ambulance” or “what do you mean there’s a bill.” To get the raving fans in the public that other public services like the fire department, parks, and libraries have, we have got to create a generation of educated, raving fans who will advocate for EMS.2) Also speaking of promotion and education, we don’t educate or even prepare the people we promote. “Fred is a good medic. Let’s make him a training officer” is soon followed by “Fred is a good training officer. Let’s make him a supervisor.” None of this is accompanied with any leadership education. And when you don’t develop leaders, at best, you develop managers. Managers look at metrics and take direction, then pass it down the chain. In other words, there are a lot of EMS managers and damned few leaders. Think about that when you’re working for an EMS provider whose business model requires you to drive around town and park in 7-11 parking lots for 12 hour stretches. The abject lack of leaders who advocate for EMS and for their team are exactly why EMS is how it is, where it is, and why the current paradigm stinks. And to add fuel to the fire, there’s more than a few of the current (and previous) generation of EMS grand poobahs who continue to dominate the EMS committees, work groups, etc. They’re hanging on to their fading relevance and routinely tell new faces to “wait their turn.” Once again, EMS has met its enemy — and it’s often us.

Friday, May 21

Another #EMSWeek thought to ponder. It’s good, heck it’s imperative, to be current on one’s medicine. And it’s right that EMS education focuses on the application of science to medicine.But that’s just one part of being informed, educated, and successful in EMS. One also needs to understand the world of EMS operations — because what makes EMS different from most of the rest of the world of healthcare is where and how we deliver medical care — namely outside of clinical settings.And perhaps most importantly, we need to understand the business, economics, law, policy, and politics of EMS. Because if we don’t own those spaces — someone else will. And invariably, those people don’t necessarily have EMS’s best interests at heart. (See also: virtually every state or Federal EMS committee where the EMS practitioners are outnumbered by the other “stakeholders.”)

Saturday, May 22

Final #EMSWeek post. I’ll leave you with two thoughts. First, it’s a privilege to do this work. Strangers trust us to enter their lives at their worst moments and trust us to know and do what’s right for them. Second, EMS can be fun. For me, it’s a huge change of pace from the practice of law and the constant meetings, emails, and issues that drag on for a long time. As long as you keep those two things in mind — and have a life away from EMS as well, it puts everything else about EMS into perspective. And if you’re not having fun with this, ask yourself if it’s you or if it’s where you’re at.

EMS – Starting From Scratch

Right now, there’s some controversy in Texas EMS circles over a pilot program to combine EMT and paramedic education into a single program where an entry level student wouldn’t need to be an EMT before entering paramedic education. I am cautiously optimistic for this concept, but I’m also sure it will need tweaking along the way. EMS is the only career field I’m aware of, at least in healthcare, where you have to obtain a lower level certification in order to advance. Registered nurses don’t have to become vocational/practical nurses first. And physicians don’t start out as physician assistants.

In this spirit, I started to wonder what other sacred cows I’d slay. With my squirrel brain, that quickly morphed into how I, your humble scribe, would completely redesign EMS from scratch.

First, get rid of the Emergency Medical Responder certification — or what Texas calls Emergency Care Attendant. EMT becomes the new certification for first responders, whether police officers, firefighters, or other personnel. On that note, aside from politics and inertia, why do we have the fire department doing first response prior to EMS arrival? Why not have law enforcement or even community based organizations doing EMS first response?

AEMT would become the minimum staffing level for a 911 ambulance. Of course, there can and should be a process for rural communities to make the case for EMT level staffing due to unavailability of AEMT and/or paramedic staffing.

Non-emergent transfers would be done by nursing aides and/or vocational/practical nurses with training in operating a van and patient movement. Non-emergent transfers should not be part of the EMS world. EMS resources should be dedicated to 911/emergency calls and critical care transfers only. On that related note, medical facilities, especially skilled nursing facilities, should be required to use the 911 EMS system for emergency calls. These facilities should also be financially sanctioned for using the 911 EMS system when a transfer company is not able to respond to a non-emergent transfer.

To supplement the 911 AEMT/Paramedic crews, advanced practice paramedics with enhanced education and skill sets in critical care and community paramedicine riding in SUVs to supplement and assist on 911 calls. These paramedic clinicians should function as true physician extenders to help patients navigate the healthcare system, engage in alternatives to transport, and considering alternate destinations besides the hospital emergency department. A paramedic clinician with telemedicine capabilities and point of care lab testing could present a huge opportunity for cost savings throughout the healthcare system.

In my ideal EMS world, there would be 3 ways to become a paramedic. Much as some nursing programs have a bridge course for vocational/practical nurses to become registered nurses, EMS needs a paramedic transition curriculum for those who are already AEMTs. Also like nursing has alternative entry BSN programs for those with a bachelor’s degree, we need a route for a paramedic certificate as an add-on for those who already have a bachelor’s degree. In this revised EMS world, most people would get a bachelor’s in EMS that covers the current knowledge base as well as the things we don’t cover, but need to advance in EMS — courses in management, policy, economics of healthcare, and adult education methods. The ideal EMS degree should be preparing graduates not only as paramedics, but as the future managers and leaders of our profession.

The current proposal of creating the associate’s degree as the entry level EMS degree accomplishes little beyond awarding college hours for what is currently, by and large, a technical degree in the career/technical education side of the community college world. EMS is a medical field with more in common with nursing, respiratory therapy, and dare I even say, medicine than it has in common with career/technical education like diesel mechanics or heating and air conditioning repair.

Everyone wants to fix EMS, especially those of us in EMS. All but the most naïve realize that any solution is going to require funding. Funding is a challenge whether the service is directly funded by the government or whether EMS is a private entity. There’s one untapped source of EMS money that most of us aren’t considering. As the more astute in EMS know, the Center for Medicare/Medicaid Services (CMS) only reimburses EMS for transports, not treatment. Until EMS speaks with a united voice and focuses our Federal legislative efforts on this change as opposed to quixotic, feel good legislative initiatives, we are doomed to poor pay, poor equipment, and a seat at the kids’ table of the Thanksgiving dinner that is the American healthcare system.

Am I wrong on this? Maybe. But unlike a lot of the others purporting to speak for EMS, I’m not unwilling to challenge the status quo. Johnny and Roy are but a memory to the newer generation in EMS and it’s time that we stop considering the original model of EMS responding to cardiac events and collisions as what constitutes an EMS system, much less a functional, successful EMS system.

The Right EMS Degree

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