The greatest Commandant the United States Marine Corps has had since World War II was General Al Gray.  General Gray, channeling the spirit of every Marine, famously stated, “Every Marine is, first and foremost, a rifleman.”  He captured the essential nature of being a Marine.  Every other role that a Marine has or is trained for is secondary to and a condition of being a rifleman.

Wait, Wes.  How does that quote relate to EMS, which is what you mostly blog about? Elementary, my dear Watson. EMS is, whether you’re an Emergency Medical Responder, an Emergency Medical Technician of the varying levels and flavors found in these fifty amazing states, or a paramedic, fundamentally based on responding to emergency calls for assistance, regardless of the platform that you’re responding on.  Whether it’s the 1966 NHTSA White Paper, Dr. Pantridge in Belfast, Freedom House in Pittsburgh, or the fictional (BUT so influential) Squad 51 in Los Angeles County, EMS was created on the basis of its very name. Emergency.  Medical. Services.

And the reality is that EMS education, whatever flaws it has, is fundamentally based on producing a safe, entry level provider theoretically capable to providing initial emergency medical care, whether it’s CPR, bleeding control, advanced airway management, or the management of an acutely ill patient with medications.  That’s what EMS education produces.  And that’s what EMS professionals are trained for and should be doing.

Yet, for some reason, there’s a crap ton of EMS people who think the role of a 911 provider is somehow beneath them. I have an update for you.  It’s not. It’s literally who you are and what you were educated (or trained) to do.

Both in real life and online, I’ve observed what seems to be a constant. The people who talk the biggest game about their clinical acumen and are the most certain of their answers, whether correct or incorrect are among the biggest frauds to hold an EMS patch.  They almost always have one common trait.  Namely, virtually none of them have significant tenure in  a 911 EMS system – or have experience somewhere where the wheels turn only a few times a day.

I’ve met a long list of these people online and more than a few in person. They eventually get found out. I can remember one of these people who some of us on social media referred to as “Doctor Google.” This guy could recite facts about the most obscure conditions and the related pharmacology, but couldn’t hold down an actual 911 job because of his innate arrogance and off-putting tone.  I’ve known others who think that a 911 job is beneath them so they can work in an emergency department or in some vague notion of “critical care” in the hopes that the collective wisdom of the physicians, advanced practitioners, and nurses will rub off on them. And perhaps the biggest fraud I’ve ever met had experience as a transfer medic, then an overseas contractor.  They flexed that experience into several PRN flight gigs, then wormed their way into a leadership position in rural EMS, where they eventually were exposed. After several stints in freestanding emergency departments, they ended up in EMS education full time before seeming to gradually move on from EMS. After working with that person for a while and even trying to help them find an actual opportunity in 911 EMS working for a service that, at the time, offered some of the highest call volume and acuity in the Lone Star State along with aggressive protocols, I finally figured it out.  They were afraid of actually being on an ambulance, let alone being around people who might recognize their shortcomings. Ironically, despite the tough talk and rough attitudes, that service was known for never giving up on someone who had the drive to improve. (And for what it’s worth, I owe much of whatever success I have in EMS to that department.)

In conclusion, just as every Marine is fundamentally a rifleman, every EMS professional is fundamentally a 911 provider.  Those are what the initial goal and the foundations of our education are about.

911 EMS isn’t a distraction from whatever path you’re on.  It’s how you got on this path. And it’s, by and large, where EMS professionals belong.

It’s not an insult to be on an ambulance (or a fly car or even a fire truck).  It’s why you’re here.  It’s what you do.  And it’s what your patch says. Emergency. Medical. Services.

Don’t be the fraud.  Be the medic you wanted to be when you first found this field. And, if you can, leave this field just a little better than you found it when you came in.  On that note, you don’t have to fix EMS as a whole.  You can fix one system at a time.  Or even one student, colleague, or patient at a time.

As a Texas paramedic and attorney as well as having worked EMS in the Hill Country over the years, I’d be remiss as a blogger if I didn’t at least put some words and thoughts about the floods and the accompanying loss of life that came with them.

First, I need to blast, and I mean literally blast, a Houston area pediatrician and a former president of the State Bar of Texas who took advantage of the tragedy and the loss of life to not only politically pontificate, but to insult the lives lost and claim that the loss of life is what Trump voters voted for. If you know me, you know that I’m to the right of Trump. (Yep, that’s possible.) But damn, when a tragedy hits, if you’re not offering help, condolences, or even prayers, shut your mouth. Period. Part of the vows I’ve made professionally and to myself tell me that I don’t care what your politics are if you need help. Again, while Christianity is not my faith, I’ll leave words from the Book of Matthew. “I was sick and ye visited me.” Matthew 25:36.

And I’ll add one more point of personal privilege. If you’re blessed and fortunate enough to be entrusted to care for and protect others, this incident isn’t the one to make fun of. I had someone who I considered to be a good friend, even if they are immature, make a horrendous, ill-timed joke of the loss of life. He’s no longer part of my circle of friends. I get black humor. I get gallows humor. My jokes would keep me in HR for eternity if reported. But I know this. If you weren’t part of this scene or response, you don’t get to say those things. Period. Full stop. This reminds me of an incident at a previous department where a responder who was NOT on scene at a fatal crash made jokes about “barbecues.” Again, some things are just beyond the limits of good taste. If you weren’t there, you don’t get to joke about it. And if you were there, you probably won’t joke about it.

As for the floods, I’m not assigned to these incidents for a variety of reasons relating both to my lack of swift water training and my current role at my current department.  

I’ve seen a lot of tragedy.  I’ve responded to a lot of incidents for over 20 years. It’s not just the big disasters.  It’s the little tragedies that constantly pile up.  I’m always amazed by which incidents and moments stick with me.  But serving my fellow Americans and Texans is the highest honor and privilege of my life.  

For those of you wondering what this life is like, I would encourage you to read Johnny Joey Jones’s book “Behind the Badge.” It’s probably the best reflection of what those of us with a badge do. 

I complain about my EMS stuff way more than I should. It’s given me some additional meaning to my life aside from editing contracts. The BS is there in every EMS agency (or fire or police too). It’s just a different stench depending on where you’re at.

But there are two things you can always be certain of in these fields.

1. The people who last in it are the people who got in it to help people.

2. The friendships you make are amazing.

All the complaints aside, it’s been a fun 20 plus year ride. I’m eternally grateful for it. And every time I think I’m ready to say “F this, I’m done,” the universe reminds me that my tank isn’t that empty. Y’all are stuck with me for a little while longer.

Me?  I’m back at the office doing attorney stuff tomorrow morning. And truly frustrated that I can’t get out and be a paramedic as much as I’d like. Sadly, the opportunities for volunteering in public safety have shriveled over the years. And many of the remaining volunteer opportunities, at least for a Texas paramedic, aren’t nearly what they used to be, either.

Y’all be safe and hug your family. 

Lately, a lot of the EMS social media pages have been giving advice to new medics and students. Some of the advice is good. Some of that advice is not good, which is a charitable understatement, to say the least. So, today, when a medic student asked me for advice, here’s what I told them — and also just added onto.

Here are things you’re not going to learn (or learn enough) about in a paramedic program.

1. Prescription medications. If you know and understand the medications that your patient is taking, half of your assessment is already done.
2. Understanding physician specialties, the roles of other healthcare professions, types of healthcare facilities, and hospital capabilities. This makes sure you get the right patient to the right facility. As a point of personal privilege, if your EMT partner can run the call without ALS intervention, that’s the only time you should even consider transporting to a hospital without ICU beds. (Yes, little old Mrs. So-And-So with the UTI is sicker than you think and she’s quite likely gotten herself an ICU admit.)
3. The ability to talk to a patient. A SAMPLE history and OPQRST aren’t enough. Period. Those start the questions.
4. For every patient you see, think of 5 possible differential diagnoses for them. Use pertinent positives and pertinent negatives to narrow down your diagnosis. (A special thank you and tip of the ol’ Resistol to the dearly departed Gene Gandy for that advice.)

Here are things to remember right now.

1. You’re not expected to have this down while you’re in school or while you’re the “new kid.” That’s why you’re in school or a new hire.
2. If you think you have it down, go Google the Dunning-Kruger effect.
3. Pay very little attention to the self-proclaimed EMS experts online, especially the EKG nerds. Many of those nerds speak with a great deal of certainty about subtle EKG findings that neither impact prehospital care nor are they absolute. Cardiologists will quibble about these findings.
4. There is nothing in any law book that limits the scope of your education. Have at least one physician level text on emergency medicine, or better yet, internal medicine. So much of what EMS does is what I call unscheduled internal medicine.
5. You become a good medic by seeing lots of patients. Emergency medicine, whether prehospital or in the ED, is based upon pattern recognition.
6. Go to a busy EMS service to get experience, whether it’s for your clinicals or your first few years of work. See above about pattern recognition.
7. It’s ok to be eager. It’s ok to be nice. Being “salty” isn’t a badge of honor. Nor is self-diagnosing yourself with a mental health condition because you’re in EMS.
8. Have a life outside of EMS. (Unless you’re a lawyer. Then EMS is your life outside of law.)
9. Humor at the patient’s expense isn’t funny. But it is a good way to learn about unemployment.
10. The call may not be important to you, but it’s the most important thing to happen to that patient today.
11. Be nice. Nice medics don’t get to meet lawyers.
12. Always remember that if something goes wrong, your patient care will be judged by twelve people who couldn’t get out of jury duty.
13. Lucky #13. Remember in ACLS where it says “Seek Expert Consultation?” That’s not the paramedic. It’s not even an emergency medicine physician. It’s a cardiologist or perhaps even an electrophysiologist.

And speaking of EMS social media, here are some things to remember about some of these “influencers” or pages.

1. A good chunk of them are wrong.
2. A good chunk of them are warning signs. (Fun little tidbit. Some EMS medical directors and chiefs have sock puppet accounts from where they can observe Social Media Assisted Career Suicide.)
3. A significant portion of them are self promoters.
4. Some of these people serve as a living, breathing example of why EMS doesn’t get to sit at the big kids’ table of medicine.
5. Many of these people aren’t nearly as experienced as they claim to be. Their Google Fu is much stronger than their actual experience caring for a patient.

After a little over twenty years of doing this in between reviewing contracts and nasty letters, I wish someone had told me more of these things. And on that final note, that first impression counts for something, whether it’s for a clinical, a job, or that first patient contact. Tuck the shirt in and shine your boots occasionally. (Dear God, that makes me sound old. But then again, I am….)

Garison Keiler used to describe Lake Wobegon as “‘Where all the women are strong, all the men are good looking, and all the children are above average.” EMS has a similar malady. Not every EMS system is “progressive.” Not everyone in EMS is an “operator.” And not every educator or continuing education event is “high speed.” Sometimes, it’s not even cutting edge.

If you go to almost any EMS recruiting advertisement, you’ll see them describe their system as “progressive.” Now in this case, we’re not referring to AOC or Bernie Sanders. Most EMS recruiters are referring to some whiz bang aspect of their protocols. Truth is, I’m amazingly happy as an ALS hobbyist at a service where we’re entrusted with delayed sequence intubation, blood administration, IV pumps, and IV antibiotics — all on standing orders. And bluntly, in the year 2025 with the availability of video laryngoscopy, the ability to pharmacologically manage an airway should be a given. (Spoiler alert: There are indeed EMS agencies describing themselves as progressive where this given isn’t happening.) But clinical is just one aspect of progressive and it’s the easiest to advertise. You want progressive? Let’s talk about a system that manages provider fatigue, supports mental health, has stations as opposed to convenience store parking lots, and has leadership with qualifications above and beyond good clinical skills. What would be truly progressive is a decent salary that means you don’t have to pick up extra shifts unless you want to and a defined benefit pension system. And for what it’s worth, such systems do exist.

On this note, not everyone in EMS is an “operator.” This is especially true in the world of EMS education. EMS education, present company excluded, often consists of three categories of people. Category one consists of the jaded medic who’s unable to work in the field anymore. What passes for education from them is reading the PowerPoint slides and interspersing dated dogma and war stories. Category two are the entertainers. These people are fixtures on the conference circuit. Whatever the subject, they’ll teach it, regardless of their subject matter expertise. They often have catchphrases, a uniform that looks like something out of a banana republic, and/or a persona that may or may not match their field expertise. Finally, we have the terminally arrogant. These people delight in proving they’re smarter than you. Whether it’s obscure EKG findings, clinical zebras, or plain ol’ data analysis, these people and their acolytes have their following at conferences and on EMS/medical social media. Honestly, these are some of the smarter people in EMS. Their biggest problem is that they know it and want you to know it too. See also: “I’ve got two years of paramedic education and I’m going to speak with absolute certainty on findings that fellowship trained physicians at academic medical centers may quibble over.”

And for those EMS providers who think they are indeed above average, there’s a whole class of frauds, posers, and grifters with flashy course titles and cool social media combined with dubious credentials or expertise. In fact, if you wear enough camo and use the right buzzwords, you can get people’s continuing education money even when the courses are no longer accredited. (Not to mention taking money from gun enthusiasts and other “outdoors” types who will instantly take courses and buy products from anyone who claims they’re tactical.) On that note, being a military medic, in many cases, means you’re very good at managing trauma in healthy young people. The definition of confusion can often be a military EMT or paramedic making the transition to a civilian 911 position and getting their first geriatric respiratory patient. And just like the “regular” EMS people, “cool” social media will always sell. This week, in fact, I saw social media advertising from one provider of “austere medical and rescue services” that crossed a very clear line in terms of medical decorum. In other words, it’s not just the regular EMS medics who have some work to do — it’s also the supposedly smart people.

Me? I’ll settle for competent EMS providers of all levels who can run a 911 call with good clinical skills, the appropriate level of compassion, and maybe, just maybe, getting the right patient to the right care. And none of that requires you to look like you’ve been operating behind enemy lines. Even more so if the biggest battle you’ve fought is dodging a dialysis transfer.

Those of you who know me know that I believe initial EMT education is, to use a play on words, way too basic. I have also told many of my friends, particularly those in EMS, that a paramedic certification, even without a degree associated with it, is an excellent return on investment. I’ve mentioned that there are a lot of degreed professionals (teachers, social workers and even more than a few lawyer positions) that earn less than many paramedics, particularly if the paramedic works for a public EMS agency.

I’m also a conservative, so I have some skepticism of government trying to “fix” a problem. I’m reminded of Ronald Reagan’s famous quote, “The nine most terrifying words in the English language are ‘I’m from the government and I’m here to help.’” And during the pandemic, everyone reported there was a shortage of EMTs and paramedics. So, in many places, the government came in to help. At least in Texas, the state created a fund to reimburse tuition for people getting initial EMS education at any level contingent on working or volunteering for an EMS provider.

And I think this very well intentioned and noble piece of legislation is about to create an affordability crisis similar to that which many are experiencing in higher education, which we see manifest itself in two ways. First, the amount of student loan debt that people have accumulated to get a college degree. Second, the increased prevalence of degrees and advanced degrees has meant that employers are even more selective, leading to situations where people with degrees can’t even get interviews for entry level positions. Worse yet, student loans are funded and guaranteed by the Federal government, which means that colleges have no pressure to control costs as the Federal government guarantees the loans in the event of default — and unlike much other debt, student loan debt is not typically dischargeable in bankruptcy.

Just this morning, I saw a Texas hospital offering an EMT class for $1875. To provide some frame of reference, I paid $500 for my EMT class in 2004. My class was held in the classroom of a suburban fire department and taught by a few local medics who thought that teaching an EMT class was a better way to make extra cash than overtime shifts. In 2006, I paid $3000 for the only night paramedic class offered in the Austin area, a class that was run by a private EMS company.

In part because of the indirect state subsidization of EMS tuition and the increased requirements of EMS education accreditation (at least at the paramedic level), going from mild-mannered attorney to EMT to paramedic for the total of $3500 (plus, of course, random incidental and indirect expenses) is no longer achievable.

These subsidy programs come with a few challenges.

1. Not everyone may receive the subsidy or grant.
2. The funding (at least in Texas) requires you to work or volunteer on an ambulance for a set amount of time. As I’ve mentioned before, at least in my area, part time opportunities for EMS are not what they used to be and volunteer opportunities are slim. (This presents a challenge for both volunteer providers and for those potentially considering a career change.) Additionally, at least in Texas, this state funding requires that you work on an ambulance. Texas has a separate category of non-transporting EMS entities called first responder organizations that provide EMS care until transport arrives.
3. Unlike attending a college or university, EMS education programs (at least those not operated directly by an institution of higher education) don’t award academic credits, hours, or credentials that are portable elsewhere.

Alas, despite the increased requirements and costs of EMS education, working conditions and salaries are not keeping pace. Many of the same challenges in EMS retention that the pandemic made worse are still there. I still stand by my assertion that EMS pay isn’t the problem. Rather, it’s what EMS providers have to put up with for the pay. (Read that last sentence SLOWLY if you want to understand the volunteer crisis.) If we’re going to fix EMS recruitment and staffing, we have to address retention. All of the subsidized tuition in the world won’t fix EMS retention. We fix that by professionalizing EMS management. All the clinical education and expertise has little correlation to being an effective EMS supervisor, manager, administrator, or leader. (See also: my regular assertion that the best degree for an aspiring EMS chief/director is a public administration degree. You already know how to do EMS things. You DON’T know how to manage, lead, and administer people and an organization.)

At the paramedic level, the accreditation requirement has created a virtual monopoly for college-based EMS education programs. The colleges, by virtue of being the primary providers of paramedic education combined with subsidized tuition, have created a monopoly which, in particular, has limited access to EMS education for rural providers or nontraditional, working students. While there are indeed online programs outside of a college setting, these programs often must pay to affiliate with a college as a “satellite” campus and again can charge whatever they want because they’re the only game(s) in town if you’re working elsewhere or living outside of a metro area. While accreditation has likely driven some of the worst EMS education programs out, accreditation largely only guarantees that the education program is organized and has policies to administer the program. Accreditation does not guarantee the quality of the education provided.

If we think that higher education alone will improve EMS, I’d caution you to examine the example of Australia, a country that many in EMS consider to be “excellent.” The universities in Australia have no incentive to control the number of paramedic graduates for a relatively low number of paramedic positions in their country. This means that one of Australia’s more notable exports as of late have been Australian paramedic graduates. Whether they’re working in London for the London Ambulance Service or in Texas and Louisiana for Acadian, Australian paramedics aren’t working in Australia because the jobs aren’t there, but the degrees are.

In conclusion, I’m worried that we’re making EMS education less affordable and less accessible while still leaving our retention issues unaddressed. If only we had EMS leaders with an understanding of law, policy, economics, business, and the political process than in the current clinical trends on EMS social media. Interestingly enough, many of the hurdles involved in adopting these latest clinical trends would be lessened if we had EMS leaders with an understanding of law, policy, economics, business, and the political process.

Meanwhile, enjoy the current EMS staffing challenges — which an $1875 tuition for an EMT class isn’t going to improve one bit.

The other night, when I was a bit sleepless, I ended up on a YouTube rabbit trail and watched a few medics’ videos of their “everyday carry” (AKA – EDC) of what they wear or carry on shift. After watching a few of these (and having opinions on where I’d differ from them), I decided to share my opinions based on my twenty-ish years in EMS. Of course, your views may differ and mine are based primarily on experience as a 911 medic based out of a station. I’ve also done volunteer first response from my own vehicle and I’ll add something based on that too. I know this should be a YouTube video or maybe even a TikTok, but I’m old and cranky, so you’ll get to read my opinions. Also, I’m not making any money from any product I recommend. But being an attorney, I can be bought….

First and foremost, if you’re doing EMS and doing it seriously, you need a stethoscope. I’ve tried a variety of ears over the years from Littmann, MDF, ADC, and EKO. I have an EKO Core 500 (the one with EKG). It’s amazing, but it’s suboptimal for the EMS setting. The chest piece is big and awkward, which means you’ll have a hard time getting an auscultated blood pressure. Day in and day out, I’m a Littmann fan for everyday EMS use and the Cardiology IV is the one I rely on every shift. I change the other side of the chestpiece to the bell, which makes blood pressures easier and also helps with heart sounds. The EKO Core 500 is a game changer, for sure, but I think it belongs more in the primary care office setting for a quick and dirty EKG for referral purposes — or similar for possible heart murmurs.

I’ve owned more than a few radio straps over the years because they’ve been “trendy” or “cool.” I never fully understood the love for these, especially if you’re not in a fire-based system where you might need to wear a bunker coat over the radio. Further, a radio strap is a bit awkward if you need to get your radio out to change which channel or talkgroup you’re operating on. So, I’ve fallen off that bandwagon, and believe it or not, I’m back on the idea of a duty belt. Note — you do NOT need to adopt the mindset of a few EMS systems in Central Texas where the duty belt looks like a police belt with almost every space filled on it. So, here’s what I have on my belt. I keep my phone in the Condor Phone Pouch. The outer strap carries my phone. The inside zipper compartment is surprisingly spacious. In there, I have a few extra gloves, a Streamlight ProTac EMS light (as my penlight), a pair of Raptor shears (do you really need a link?), a Hogue trauma knife, a Sharpie pen, and a notepad. On my outer belt, I also have a Condor radio case for my handheld radio. You’ll note that I don’t typically carry a tourniquet or any other bleeding control supplies on my belt because I’m rarely, if ever, on EMS duty without immediate access to bags with those supplies. Also, if your agency issues metal badges, and it’s permitted, a duty belt is the perfect place for a badge when attached to a leather badge clip.

Sometimes, especially at night, I choose to carry a separate flashlight. When I do, it’s almost invariably the Streamlight Strion LED HL. I’ll either carry it in a holster on my belt, or in one of the small pockets on my cargo pants.

On my personal key ring, I carry 3 EMS related things. One is a USB drive. The one that I bought has both the USB A and C adaptors as well as a leather case to attach to my keyring. I also have a CRKT K.E.R.T. keyring multitool for cutting and for its oxygen wrench. Finally, the keyring has a Streamlight PocketMate light for when I need a quick light.

If your employer isn’t buying your uniform pants or if you can buy your own, I’ve become a huge fan of Condor’s products as they’re often cheaper than that other big named brand, a bit more comfortable, and at least in my case, fit just a bit better. If you want EMS specific pants, Condor makes those with the EMS pockets/scissors strap. There’s a ladies’ option as well. If you want tactical pants without the classic EMS pockets, their Sentinel pants are great. I really like the rings on the belt loops to hold an ID card as many Texas departments have department ID cards that we’re required to wear on duty. (Unfortunately, they don’t currently make a pair of these pants designed for women.)

When it comes to footwear, you should never compromise. As far as I’m concerned, boots and a stethoscope are the most important investments you’ll make for your comfort and success in EMS. I’m a fan of HAIX boots. I’ve had several pairs over the years and I consistently go back to my HAIX Airpower XR1 Pro boots for comfort, warmth, and protection. They’re NFPA rated for EMS duty along with wildland, rescue, and hazmat. I also recommend some good socks when on duty. I like the Fox Tactical Boot sock most of the time. I’ve also tried compression socks, which a nursing friend recommended to me. I’ve had good luck with those, especially for days where I’m on my feet for extended periods.

When I’m on shift, I still take a go bag with me for some personal maintenance and comfort items. I take a shaving kit with my eyeglasses and contact lens supplies. I also bring a portable battery/charger for my electronic devices (especially my Google Pixel 8 Pro phone, which I’ve paired with my Pixel Watch 3). In the bag, I also have different USB and power cables as well as a change of socks and underwear. I’ve found a need to clean a mess on my clothes before. As such, I keep a box of Shout Wipe & Go wipes to provide at least a partial cleanup until I can get to a washer and dryer. I also keep a package of Whoosh screen cleaner to clean my glasses and screens. As for the bag, I am a huge fan of Hawke’s Mini Smokey bag. In fact, this bag has become my default bag for almost all travel that’s less than two days.

When I’ve worked EMS first response from my car, I found that the police-style patrol bag/seat organizer was a great way to carry a lot of what I referred to as “office supplies” that I’d need to grab from the front seat of my SUV. In there, I’ll usually keep a box of gloves, hand sanitizer, a metal clipboard for paper report forms, my traffic vest, my tablet computer (unfortunately my original Microsoft Surface Go has been discontinued), a large notepad, more pens, and also a spray bottle of hydrogen peroxide to get blood off of my clothes until I can change.

And before I close this out, I almost forgot to mention the pen that I’ve used since my senior year of high school. The Zebra F-301 ballpoint pen in black was the first pen that I saw used by uniformed public safety. Not only is it still used by many in uniform, it’s still my old reliable. (For what it’s worth, when I was first responding in my own vehicle, I did keep a few “disposable” pens in my clipboard case when I was going to have someone else sign a form. EMS conferences and other conventions are the best place to get free “disposable” pens.)

On a final note, I’d recommend a couple of apps for your phone. The Critical – Medical Guide app is available for both iOS and Android. I think it’s the perfect “pocket guide” EMS reference. You’d also benefit from having a protocol app for your department, if one is available. A stroke scale app and also a drug reference round out my recommendations for EMS providers of all levels.

I hope this helps and provides some useful guidance for those looking for EDC advice. You’ll notice that I mentioned very few things in terms of medical equipment/supplies for a simple reason. Namely, your employer should be providing you those things. The things I’ve recommnded are extra items to make your job easier or things you should be getting on your own anyway.

As always, your mileage may vary.

Those of you who know me away from the computer screen (and many of you who do know me only via the screen) know that I tend very conservative. I mean, very conservative. I’m not a libertarian for a variety of reasons, largely because libertarianism is based on a very idealistic view of people and society. (The best argument against letting people do everything on their own with very few controls can best be witnessed when you see what passes for pop culture.) Nor am I of the anarcho-capitalist mindset that so many online edgelords think is cool.

I do believe there is absolutely a role, albeit a limited one, for government. I also believe that which government must do, it must do well. That requires adequate funding. Notice that I didn’t propose a blank check. It also requires accountability for results. It requires transparency. When a Chevy will do, you don’t have a God-given right to a Cadillac or even a Mercedes. It’s not your money. It is the taxpayers’ money. Many in public service have lost sight of this. I call this “other people’s money.” And like my libertarian friends, I don’t believe you have an automatic right to other people’s money. As Justice John Marshall said in 1819, “The power to tax is the power to destroy.”

So, on that note, let’s segue into a part of the public sector that has felt an entitlement to your money. This part of the public sector operates as if it has an entitlement to your money as they claim they provide an essential service that no one else provides. They claim a long history dating in this country back to Benjamin Franklin. Their union members (and union leaders) as well as their administrators work hand in glove to ensure that they receive more and more from the public trough. They ask for, and receive, spacious facilities and state of the art equipment and technology to accomplish their stated goals. When they come to the public or governing bodies for more of your money, they present themselves as community heroes and public servants who are asking for “pennies a day” or “the cost of a cup of coffee per week.” If you ask them for results or challenge their narrative, you’ll be told that you’re threatening their very mission unless you give them everything you want. Oftentimes, these “dedicated public servants” use taxpayer money to lobby for more money for themselves, for more unionized jobs, and for higher salaries. And while some suburban and rural areas get this delivery of a crucial public service down, many urban areas are an abject failure at providing this core, essential service that we as Americans expect from the government, primarily at the local level, but also with significant state and federal funding. And while many of their union members are right of center, their union and union leadership take far left progressive positions that alienate many of their members and much of the public. The oversight of these local service providers typically is performed by locally elected bodies who often function as little more than a rubber stamp for the administration who will approve tax increases and bonds in lockstep.

For my friends on the right, this sounds a lot like the public school system that has become a bete noir for the right. But this time, I’m NOT talking about the public schools, the teachers’ unions, school funding, or education politics. It sure sounds like them, doesn’t it?

Surprise. I’m talking about the American fire service. I’m talking about their left-leaning union – the International Association of Firefighters. I’m talking about their association for administrators – the International Association of Fire Chiefs. Let’s face it — have you ever seen the IAFF and the IAFC not present a united front to ask for more staffing, more apparatus, and more stations? When you oppose more money to what I’ll now call “big fire,” you’re demonized as un-American, as not caring if people die, and for being an all-around heartless SOB. And just like the education system, these folks make themselves out to be your local heroes. The reality is that, in many locales, building codes and modern construction have drastically decreased the need for structural fire suppression. That means that the American fire service has had to find new roles to remain relevant. In many communities, that’s meant expansion into EMS, whether it’s basic life support level first response, advanced life support (AKA, paramedic) first response, or operating an EMS transport division as part of the fire department. In fact, in many places in my home state of Texas, fire departments that are operated as a special local government district (we call them Emergency Services Districts here) have gone right back to the taxpayers for a second district to fund EMS separately even though the EMS service is part of the same fire department. Especially in larger departments, EMS is seen as a distraction from the “core” suppression mission. I know of at least one urban fire department in Texas where EMS duty on an ambulance is called “riding the penalty box.” All too many fire departments mandate paramedic certification for hiring or promotion. All of this creates a culture where prehospital medicine is shunned, where the funding for the EMS side of the department is bare bones, and where EMS training “meets minimum standards.” Look no further than the average fire department’s social media. Hashtag Always Training is almost invariably about structural fire suppression training. This isn’t only happening in metro areas with big departments. I’ve watched a volunteer fire department’s membership approve a $15,000 drop tank without discussion while they claimed poverty in not being able to buy an EZ-IO device for their paramedics and while their advanced airway supplies were stored in a gym bag. Like the school districts, those elected or appointed officials overseeing Big Fire rarely question anything the chief or the union presents them. Rather, they just turn on the spigot for more money. In fact, in Texas, there’s even an association (that lobbies the Texas Legislature with district funds) for these Emergency Services District commissioners. Just like the association for school board members. And just like many urban school districts and their lack of results with their core mission of education, all too many fire departments, particularly bigger ones, fail at providing competent, let alone GOOD, EMS care. Just like public education, Big Fire in many locales has become little more than a jobs and public works program funded by tax dollars while everyone else complains about rising property taxes. For everyone who complains about school districts’ spending on things like football stadiums that rival some NCAA programs, I’ve yet to see anyone question a suburban or rural fire department buying a tiller ladder that’s well over $1 million.

I honestly don’t oppose the fire service. Truth be told, in a lot of locales, the fire service even does a good job at the delivery of emergency medical care. But I want the public, especially those on the right, to view the fire service and their requests for MORE money with the same skepticism and demands for results, accountability, and transparency that they rightly demand of public education. It’s the public’s money. Those entrusted with it have an obligation to do better with it.

Well, it’s once again EMS Week. Or to everyone else in healthcare who’s not an EMT or a paramedic (and yes, there’s a BIG honking difference), it’s Ambulance Driver Week.

And for most hospitals, that means y’all will feed us (don’t forget we’re a 24 hour operation) presuming the staff doesn’t graze over our meals as well and/or give us swag festooned with your hospital logo all over it. Don’t get me wrong. I love food. I love cold drinks. I can always use an extra pen or pair of shears. And I love the EMS room at a lot of the hospitals I’ve been to. Sometimes, that snack is all that’s keeping me, your facility, and our patients from me getting hangry.

But there’s more I’d appreciate from the hospitals, nurses, and doctors. Every year, during EMS Week, we hear how we’re your “valued partners in healthcare.” Valued partners get real recognition and partnership every week of the year, every day of the week. And there’s at least some of us who would like more of a partnership than a week with a taco bar or a regularly stocked EMS room. (Like I said, I won’t turn away food.)

But a real partnership means more than that. A real partnership means including us in education. I’ve lost count of how many colleagues in EMS education tell me about hospitals turning down EMS education programs’ requests for their hospital to be a site for clinical rotations. Those sites that do remain know they have EMS educators at their mercy and such clinical agreements have become something that it takes a lawyer to review, read, and understand. (Fortunately, I know an attorney who can do this.) Further, these clinical site agreements now have more and more restrictions on them, specifically now requiring the EMS education program to send a paid preceptor to supervise the students. A real partnership with EMS means allowing EMS students to “do things.” Labor and delivery rotations shouldn’t be “observation only,” especially when nursing staff loudly asks the mother “You don’t want a male EMT/paramedic student in here, do you?” Clinical shifts should be more than “observation or basic life support only” for paramedic students. I am tired of hearing pediatric facilities complain about their perception of EMS providers being weak at pediatrics when they won’t allow EMS students into their facilities or severely limit their participation as they tell us, “All you need to know is to bring the kid here. WE are the pediatric experts.” (And don’t get me started about a certain Houston pediatric hospital mandating that EMS get vital signs on the hospital’s blood pressure monitor as opposed to accepting EMS obtained vital signs.) And for the doctors who say that paramedics shouldn’t intubate or do other low frequency, high acuity skills, when will you allow EMS students as well as current providers the opportunity to get into the operating room to intubate or to shadow you?

There absolutely are EMS providers who are as passionate about professional development, growth, and excellence as anyone on the other side of the hospital doors. There are also those of us who pencil whip continuing education and have to be dragged kicking and screaming to accept changes in medicine. There are similar providers inside the hospital as well. I can usually recognize these folks when they refer to oxygen saturation as “O Two Stats.” But for those of us who want to learn, make these opportunities available to EMS. At least some of us will attend.

If we’re truly partners in healthcare, treat us as such. Allow this partnership to benefit our collective patient population. And if the altruism doesn’t convince you, consider this. I did my EMT rotations all at one hospital. I did all of my paramedic rotations in the emergency department and intensive care department at the larger hospital in the same network. My family has used that hospital network virtually exclusively since I obtained my EMS certifications. I have recommended this network and their physicians to many other friends. If nothing else, this hospital network opening their doors to a student has paid off many times to the network and their associated physicians, bringing them patients (and revenue) they would have never seen otherwise.

I truly do love the hospitals, nurses, and physicians that I get to work with regularly. I don’t expect tokens of thanks. I won’t turn down a cold drink or a snack. But the education and collaboration would be a special treat on EMS Week and every other week.

We’re getting closer and closer to EMS Week. What does that mean? For many of us, it leads to a slice of cold, cheap pizza and some random piece of EMS Week swag. For others, it’s a chance for them to prove their bona fides as either an “EMS leader,” “emerging leader,” or “opinion leader.” Most of these people will either share some sort of clickbait, shopworn idea, or conventional wisdom in order to remain relevant or to get clicks.

Since I preach from the pulpit of the “EMS Church of the Painful Truth,” I’ve never been relevant in the usual gang of EMS people trying to solve the problems they helped create nor am I cool enough to be worthy of clicks. As such, here we go with my take on where EMS is these days, at least in my part of Texas.

The hot topic in Texas EMS as of late is the impending dissolution of the MedStar system in Fort Worth and Tarrant County to be replaced by an EMS division of the Fort Worth Fire Department. There are a lot of unknowns (both known and unknown unknowns) about how this will look. Will the medics be covered by state civil service laws? Will the new FWFD EMS cover the other communities under MedStar? But one thing is clear to anyone who’s not a MedStar executive or an EMS consultant. The public utility model of EMS is broken. Contracting EMS out to a private contractor to operate “high performance EMS” (AKA posting at street corners) no longer works. With the current EMS shortage that’s been exacerbated during and after COVID, there’s no longer a steady stream of EMTs and paramedics willing to work 12 hour shifts driving around a metro area. In fact, both MedStar and EMSA in Oklahoma have been unable to find contractors who meet the performance goals, meaning that MedStar and EMSA have both been operating the system directly. And like Fort Worth, EMSA’s collapse is at the point that the Oklahoma City Fire Department has moved past running paramedic engine companies to putting their own ambulances in service as “supplemental transport units.” Whether MedStar and/or EMSA have failed to effectively persuade the public and/or elected officials of their value or the fire service is better at politics (and they are), the fact is that the fire service gets public relations and political power in ways that EMS has yet to accomplish, regardless of whether you show up once a year on Capitol Hill in a uniform that confuses EMS with a hotel doorman or a third world field marshal.

That brings me to my new controversial position. And it’s one I would’ve had myself admitted to a mental health facility for less than six months ago. Namely, if you do not have a well-funded third service public sector EMS agency (whether funded by the city, county, or a special tax district), the best option may well be a separate EMS division of the local fire department. Such a system needs to have a career track for single role paramedics that extends past the two of options of working on the ambulance until retirement or “promoting” to the suppression division. Several departments in Texas (Georgetown and The Colony) have single role medic positions with an EMS promotion track. While many urban fire departments still have a struggle with accepting the EMS role, there are many examples of smaller departments, especially suburban departments, where EMS excellence and the fire service are not mutually exclusive. And with the right leadership and commitment, even an EMS cesspool of an urban fire department can make the decision to improve. The fact that the District of Columbia’s Fire Department is now administering whole blood prehospital says that the impossible is sometimes merely the improbable.

Which brings me to leadership. I’ve been a bit of an EMS nomad over the years, usually because patience is still a skill that I’m working on. In many of these organizations, I see similar challenges. More than one formerly volunteer organization in a rural area transitions to a combination or potentially even a fully paid department as the rural area transitions to a suburban area. Along the way, the growth means that those hired early in the organization’s development promote into officer and chief positions. This growth becomes even more of a challenge based on the preexisting talent pool within many of these departments where people who weren’t competitive for positions with larger departments have now been at said small department long enough to have the seniority to promote into roles they may not be capable of performing. The “Peter Principle” is a real thing and we have more than a few EMS “leaders” who’ve been promoted to a level of incompetence. Worse yet? Once these people ruin an EMS system, they pollute the rest of EMS by hitting the EMS conference circuit and/or becoming EMS consultants. In the rural EMS setting, you’ll see something similar, yet different, where a crowd of locals controls the department to the detriment of anyone from outside the clique and/or with new ideas. “This is the way we’ve always done it” and “We’re just a poorly funded EMS system” are their catchphrases.

And that brings up my final controversial idea. Civil service protections are absolutely needed in EMS. Just like unions serve a needed role as a check on management, so too does civil service provide a check on management and/or political games in the EMS workplace. Yet civil service oftern has one other challenge. Namely, internal promotions. This means that new ideas rarely get brought into an organization because civil service limits promotions to those already employed by the organization. In some organizations, the chief can appoint their executive staff, but not always. My policy prescription? Allow for external hires of officer ranks with them serving in a probationary status like any other civil service position until vested in the system. Not only will it attract qualified people to a department, such new voices destroy the echo chamber that exists within so many civil service organizations. On a similar, related note — paramedic should not be a promotion position nor should it require the completion of a department’s “special” paramedic course (looking at y’all Boston EMS, Seattle Medic One, and King County Medic One). The only time someone in EMS should be promoted to paramedic is when an EMT employed by that organization obtains their paramedic and is moved into a paramedic slot. Likewise, the only initial paramedic course that an EMS agency should offer is an internal paramedic class for those EMT employees wishing to advance professionally.

There. Several hot, potentially controversial takes on EMS that you wouldn’t likely hear from one of the usual conference speakers or consultants. Remember, y’all, I can bring these opinions and others (as well as high quality EMS medical-legal education without BS or dogma) to your organization in the form of a lecture, presentation, or an appropriately titled and compensated full-time postion. As Captain Clay Higgins has said, “I’m easy to find….”

Over the last week, I’ve had some interesting conversations with some smart people in EMS. Likewise, I’ve had some conversations with people who think they’re smart. During the course of these conversations, I noticed that a common trait of these people is that they believe their intellect alone qualifies them to be trusted to enact their vision. These same people also believe that they know better than you. Further, you should just accept what they say because they’re “experts.”

I’ll start by taking an example from EMS history that has received a lot of attention in the last few years. There’s been significant discussion about Freedom House and why it shut down. What Doctors Peter Safar and Nancy Caroline did in the infancy of EMS and advanced life support was nothing short of remarkable. It was even more remarkable to get these results with a pool of medics of unemployed men from a marginalized community. The current narrative from many of those who’ve read the book American Sirens is that the only reason Freedom House went away was racism. I’ll NEVER deny the factor of race in American society. But the book also takes time to explain that neither of the doctors got involved in educating the city council about Freedom House and then lobbying the council for support of Freedom House. There was a note of shock and surprise from the doctors that politicians (and presumably the public) wouldn’t listen to them about the value of Freedom House – because they’re doctors.

As we’ve seen in debates about healthcare and public health ever since, the mere appeal to authority does not persuade the public. Expertise IS important. Even more important is the ability to be able to talk to people to convince them. Shaming, belittling, condescension, arrogance, elitism, and smugness not only fail to persuade others, but often (if not always) cause others to dig into their position even harder.

Sadly, there’s a few EMS influencers out there trying to change EMS who haven’t gotten that message yet. Several of these people have good ideas. But their attitude and delivery is so off-putting to others that they don’t even get to sell the message. Yes, we need better EMS education (and there might be some advantages to an actual EMS degree), we need an EMS association that advances the profession, and we need to address maintaining currency and competency for current clinicians. But no matter how compelling or correct your idea is, it won’t go anywhere if your tone and delivery ticks people off before you even finish. Worse yet, you won’t even get the time of day from actual decision makers, whether that’s a chief, medical director, public official, or elected official. Good ideas go nowhere without support. Obtaining support requires more than an appeal to authority. Most people don’t like being talked down to, meaning you have to overcome that before you can even begin to convince them.

Years ago, I read a book from former Speaker of the House Tip O’Neill. He said, “People like to be asked for their vote.” Ask people to support your idea. Don’t tell them to support it. And definitely don’t tell them they’re not smart enough to understand why you’re right and they’re not. Even if you don’t think you’re doing it, your tone and delivery may be saying otherwise. A computer or phone screen doesn’t convey tone well — and it’s easy for the tone to be misread. (Cue the multiple stories of “so-and-so isn’t that bad in person.” Those are usually followed by someone else telling you their social media persona is EXACTLY who and what they are.)

Life, and EMS, isn’t a social media echo chamber, Med Twitter, or an amen corner in a chat group of your friends who are convinced they alone have all the answers. If it was, we’d see a lot of these supposed experts in EMS with the influence to match their ego – and the results to match.