COVID 19, Free Money, and Excuses

This is a bit far afield from my usual blogging about the world of EMS, but if you think big picture above and beyond considering what clinical skills an EMT or paramedic should have, maybe this is exactly about EMS.
A couple of things about COVID-19 and business and government. As most of y’all know, I’m a practicing attorney with over 16 years of experience in government law, so I think I have some qualifications to comment.
 
1) In regards to the availability of the various loans, contracts, and grants, especially to small businesses and individuals that all levels of government are providing, it’s no surprise to me that they’re not getting where they need to be. Government moves slowly, even when it’s trying to move fast. And when it does move fast, it often fails to consider how the program will work. (See the current Paycheck Protection Program loans and how they seem to really overlook certain businesses, especially the restaurant business.) There’s an art to doing business with or getting money from the government and it usually takes a level of sophistication to navigate it. Sometimes, it’s not merit that gets the money as much as it’s the person or company that knows how to fill in the paperwork best. Early in my career in state government, the state agency that I worked for regularly contracted for advertising services for a public relations campaign. The company that regularly got the contract had hired one of our agency’s former office managers.  One of said manager’s duties prior to leaving state employment was reviewing contracts and preparing the bid and contract documents.  In other words, that company knew exactly which forms to fill out and what answers were expected on the document. And how does this relate to EMS?  Simple. Let’s think about some of the EMS grants out there.  We know that certain EMS agencies nationwide have the expertise to apply for grant funding.  These same agencies get every grant they apply for  Meanwhile, there are small EMS services struggling to keep supplies on the ambulance that have neither the time nor the savvy to navigate the grant process while at the same time, the right large systems get a WMD trailer, a HazMat truck, and a tactical medicine supply that would keep the Green Berets and SEALS stocked for the next ten years.  Or there’s a Federal grant program available only to certain types of recipients.  For example, a grant for EMS may only be available to local government entities or to fire-based departments and will completely overlook private non-profit departments.  Moral of the story?  It often takes a lawyer or at least someone savvy with the ways of government to tap into the “free government money” that the media reports on.  And just as surely as the media will report on two things after this pandemic goes away.  First, they’ll report on some entity that did or didn’t get the money and why that’s a travesty.  Next, when the pandemic stockpiles get recreated and funded, there will be a story within the next two years about “exposing government waste” and a “warehouse full of supplies that no one has ever used.”
2) Failures.  The truth is that COVID-19 is causing unprecedented failures, whether in business or healthcare. And those failures need to be documented and measured so that we don’t make the same mistakes in the next pandemic or disaster.  BUT… it’s also a convenient excuse for failure too. There are stories of deaths being attributed to COVID-19.  At least here in the Lone Star State, death certificates allow for the listing of contributing factors.  So, while COVID-19 might have killed someone, their underlying conditions may have contributed. Or maybe the underlying conditions killed the patient, but the COVID-19 contributed.  COVID-19 might be the cause of death or it might contribute.  This applies outside of medicine too. Lately, I’ve been reading about restaurants “closing due to COVID-19.”  Yes, COVID-19 was probably the final straw.  But if you had a business already in decline, maybe COVID-19 was only the contributing factor.  Or you could have self-inflicted factors caused by your own business decisions. See also the restaurant that refused to allow delivery services BEFORE the pandemic and then closed one of their locations, even for to-go orders, at the first quarantine action by local government. Business, especially the restaurant business, is a Darwinian process with low profit margins.  Relevance to EMS?  I’d also note that EMS is known for low financial margins and is heavily reliant on government funds, as is much of healthcare.  Throwing any disruption into this narrow financial margin and there’s bound to be a financial catastrophe. (See also: nursing homes) In short, it’s always easier to blame an outside event than your own failings and decisions. Case in point being a long time local restaurant deciding to close “due to COVID-19” at the same time that the owner planned to close in the next few months due to retirement and rising rents.
3) And I’ve saved the most controversial post for last.  Let’s talk about quarantines, “stay home, stay safe,” or the popular phrase “flatten the curve.” I am the absolute first to say that COVID-19 isn’t the flu.  It’s a literal pandemic.  And we know that, right now, there’s neither a cure nor a vaccine. As such, we have to take drastic actions to slow the spread of the disease, save lives, and equally importantly, save the foundations of our healthcare system. And to get people to take drastic action, we have to create a sense of urgency. As such, we’ve told people to stay home.  We’ve closed schools and offices and told people to work from home if they can.  We’ve made the decision to take a massive hit to the economy to spare lives and lessen the strain on our healthcare system.  That decision is a no-brainer.  It’s the right decision and it remains so, especially without either a cure or vaccine for this disease. But the models predicting catastrophe have changed and reduced their estimates.  Granted, some places in the United States, like the New York City corridor, have born a terrible price.  (Population density is a real curse in pandemics.) At this point, if ever, we’re unlikely to know if the decrease in deaths is due to our social distancing efforts, better treatment regimens, or a flawed modeling scheme. At some point, whether now or at a still to be determined time, we will have to reopen the country and our economy.  The cure for the pandemic may be the death of our economy.  Clearly, we’re going to have to address this — and smarter minds than my own will have to weigh in.  I am pleased that our political leadership is looking for advice from those outside of the medical field.  While the medicine is crucial in this discussion, my own experience is that the medical community, probably more than any other field I’ve been exposed to, tends to believe its knowledge of healthcare trumps all other concerns and their expertise on health requires immediate deference on all other fields. Regardless, I’ve noticed that our society has changed over the four decades that I’ve been around.  Whether its societal evolution, the 24 hour news cycle, or a climate where social media gives everyone, even the unqualified, the same ability to spread their opinion, we’ve changed. The biggest change I’ve noticed is that our modern society is afraid. We’ve grown to demand safety over all else and find any risk intolerable.  Risk must be mitigated to an infinitesimally small factor. In other words, Karen from Nextdoor has become the avatar of our society.
Sorry for the rambling and the massive diversion from the usual EMS discussions.  Or wait…. maybe this discussion of government, failures, and risk versus safety is EXACTLY what EMS needs to advance.  As I’ve harped more than once, the practice of medicine (including EMS) involves much more than scientific knowledge and clinical skills. Medicine is like engineering or architecture — it applies sciences to human problems.  As such, medicine has to factor in more than the hard sciences.
Thanks for listening.

Early Lessons/Thoughts From COVID-19 for EMS.

Because the science is evolving on COVID-19, we know that the end lessons from this may be different.  But I’d like to throw of my early observations out early for consideration.

First and foremost, all of the EMS grants, training, and attention paid to tactical EMS, mass shootings, explosives, and weapons of mass destruction, the real test and draining of EMS has come from an unrelenting call volume brought on by a novel, pandemic respiratory virus.  None of the MOLLE gear and self-absorbed incident command classes are worth much in this.  Except for one aspect of incident command — namely logistics.

Second, we’ve once again learned that EMS has little surge capability. I’ve discussed this before. And most EMS (and fire) services that have transitioned from being rural/suburban combination organizations to small paid departments claim they can rely on mutual aid.  That’s well and good until EVERY system is facing the same demands. Then, you’re waiting for the state and federally contracted providers to deploy within the week.  Maintaining a part-time and/or volunteer program helps relieve some of the stress on the system.

Next, if there’s one key lesson to be learned from this pandemic, it’s that EMS needs better personal protective equipment (PPE) and infection control practices above and beyond parroting the buzzword “BSI.”

In that light, I’d hope that after this, every EMS system makes appropriate PPE available. And that needs to include changes of uniform. (I’ve lost count of how many EMS services think that the part time guy only needs one uniform shirt and nothing else.)

My recommendation for after this is to have an adequate supply of surgical and N95 masks on each rig along with appropriate cleaning supplies. Everyone should get at least 2 complete changes of uniform. Ideally, there should be a couple of pairs of scrubs on board the ambulance/response vehicle in the event you have to decontaminate before returning to the station.

I’d surmise that many of the logistics problems EMS faces stem from two things.  Number one, we stink at public outreach and education.  Most people don’t even think about EMS.  Second. we’re not sure if we’re healthcare or public safety.  That makes it harder for us to access those things reserved specifically for healthcare — or traditionally provided to healthcare organizations.  It took advocacy from the American Ambulance Association to make Amazon’s healthcare specific “store” open to EMS organizations. And at least anecdotally, the public health bureaucracy which administers the majority of the pandemic response often forgets about the needs of EMS. In fact, I’m not unfamiliar with disaster response from both my career in state government as well as my EMS work — and I’m still not sure what, if anything, EMS is getting from the Strategic National Stockpile.

What would I like to see happen?  I’d like to see proper preparation for the next time, because there will be one.  And I’d like to see adequate supplies of both equipment and personnel.  But being an attorney with experience in government, I’m a realist.  And considering this experience. I am cynical enough to have a good guess of what will happen. There will be a massive initial push to get all of this done. There may even be Federal grant money to make this happen. 99.9% of the Federal grant money will be awarded to departments that don’t really need the money. 99.9% of said awarded equipment will dry rot and expire in a warehouse. Some TV newscast will run a story on “a storeroom full of stuff that no one uses” and the stuff will be surplused. Then when COVID-2023 makes its debut, we’ll be right back at square one.

The other thing my cynicism has convinced me of is that the majority of the funds made available for the next pandemic will go to the various public health bureaucracies, certain hospital networks, and the politically connected fire services.  Why?  Because those are the people with the political savvy to navigate the legislative, bureaucratic, and grant processes.

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