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.

Last week, several EMS friends and colleagues asked me to look at the recent Kentucky case on EMS liability. Obviously, as a lawyer, my first and foremost answer is always going to be “it depends.” I’d also remind you that even appellate cases are incredibly dependent on the facts of the underlying case and the law in the relevant jurisdiction. If you’d like an in depth analysis of the case or how your organization can learn from this case, get in touch with me. I answer legal questions for a living, ya know?

Having said those disclaimers, though, there are a few things that stand out to me and bear discussion.

First and foremost, it’s quickly glossed over that the medics in question didn’t check their monitor and possibly not even their equipment. There’s no record of the daily check on either in this case. And the monitor failed to defibrillate when it needed to. As my torts professor at Texas Tech University’s School of Law used to remind us, “If there are damages, you must pay.”

Second, the court does an in depth analysis of the medics using the Active 911 phone app to navigate (incorrectly, no less) to the call when the policy manual for the department requires the use of the map book. By operating outside of department guidelines, the medics lost their qualified immunity at least under Kentucky law, under this set of facts. More on that to follow. I’d note two things, though. First, especially in rural or rapidly growing communities, maps are remarkably inaccurate no matter the source. Second, while I don’t have the trial transcripts, a good lawyer might have developed testimony to state that the Active 911 phone app does indeed constitute the use of a department approved map. Active 911 isn’t something people can just randomly download. The department has to subscribe to the service and it’s typically integrated into the Computer Assisted Dispatch (CAD) system.

So this all leads up to a long standing belief I’ve had — and it covers both the mapping issue and the equipment check issue. Namely, if you make it easier to do the right thing, people (typically even including your worst EMS providers) will do the right thing.

Over the years, I’ve encountered many such policies and processes that make it difficult for field providers to do the right thing — to the point that people either don’t do the right thing or don’t do anything at all. I’ll illustrate with a few examples over my nearly twenty years as an EMS professional.

Case # 1 – rural EMS system is worried about compliance and creates lots of policies and processes. One of those processes is to go with a system called Operative IQ for truck and bag checks to be completed at the beginning of each shift. Operative IQ in and of itself isn’t a bad platform. Like any IT solution, it’s all in the implementation. But this truck and bag check takes nearly 45 minutes — and double that time if there’s a spare truck quartered at your station. In other words, guess how many medics did a proper check of 45 plus minutes versus clicking through most things except the ones they deemed important or that required an actual number to be entered?

Case # 2A – As I call this, this is the story of the bags. I was at one rural EMS service that had a large Thomas pack on every ambulance. This was probably the heaviest bag I’ve ever carried in my EMS career. (Heck, if you want to use this bag for a physical fitness exam for new or current employees, let me know. I can hook you up with their chief.) The bag had a full assortment of trauma supplies, a D cylinder of oxygen, various oxygen masks, a complete set of intubation supplies, assessment supplies, and a full panoply of IV supplies. In other words, the bag had everything except one thing. Namely, any medications at all. Where were the medications at this service? Well, they were in a cabinet in the ambulance. Loose. (Except for the small amount of controlled meds which were in a small metal lockbox.) Again, guess how many crews took in the bag? Virtually none. To the point that the bag rarely even got checked. (By the way, did I mention that there wasn’t even an inventory or stocking list so you’d know what you’re supposed to have?) All but the least informed and laziest EMS clinicians know that it’s usually best to bring the gear to the patient and try to stabilize before transporting. But when you have a bag that makes it impossible to do so, you end up with 2 alternatives, both of which are bad. Option 1, just take the stretcher and get the patient in the ambulance. (At this service, this was VERY common with the BLS crews, who’d often resort to the funeral home days of EMS with throwing the patient on a stretcher and driving fast.) Option 2 was to bring in the Thomas pack and go back and forth to the ambulance getting the medications you needed from the shelf. Insert your favorite Benny Hill or Keystone Cops clip there.

Case # 2B – This is how you do it right. I worked at an EMS system on the far outskirts of Houston. They had their challenges – namely, try being the third crew member at a station with only two bedrooms and virtually no options to eat away from the tiny kitchen in the station. But the one thing they perfected was their bag design. First, the cardiac monitor’s pouches also held aspirin, nitroglycerin, and a glucometer. There was a trauma bag with everything to manage a traumatic injury (aside from pain medications) from bandaging and splinting supplies, IV supplies, “Stop the Bleed” type devices, and some basic assessment supplies. There was also a pediatric bag with the pouches color coded with the Broselow tape colors. But my absolute favorite was what they called the “ALS bag” that went in on every call. The bag had IV supplies, airway supplies (including endotracheal tubes and iGel devices), and medications. Better yet, the bag had two plastic cases in them. One was a case with all of the medications and supplies needed to handle an allergic reaction up to and through anaphylaxis. The other case (of a different color) had all of the medications and supplies to handle a hypoglycemic emergency. Finally, the spare medications in the ambulance were in a bag that could easily be removed from the shelf to handle an extended resuscitation or to treat a patient who needed more medications. In short, there was no reason you couldn’t bring the right supplies right to your patient each and every time. Oddly enough, while this service had its challenges, not bringing gear to the patient’s side was rarely, if ever, an issue.

Case # 3 – There are volunteer EMS organizations that issue bags (stocked at the appropriate certification level) to their members for them to respond to calls. That’s a great idea especially in areas where an EMS response may take a few minutes. But if you issue out bags and supplies to people, they need to know what they’re supposed to have AND be able to get the bag restocked without significant heartache or hassle. Otherwise, you end up with members either responding without the items they need to care for a patient or they don’t respond at all because they don’t believe they have what they need to respond. Anecdotally, we can see those things happening either by runs made by members or when a member turns in a bag that’s chock full of expired supplies and medications. How do you fix this? Step one is to make it easier to access the supply room. Step two. Organize the supply room and make the supplies easy to find. Bonus points if you have eager leadership who has taken ownership of the supply issues. Extra bonus points if the supply room now has all of the items that were on back order for eons now easy to find. (The gentleman I’m speaking of is my current EMS hero for this.) Step three. Make the supply/stocking list easy to access. Said current EMS hero recently made the organization’s protocols easy to access via a phone app — and the app includes the supply list for the bags. Speaking purely hypothetically, I know of at least one attorney/paramedic who now has a bag stocked to specifications and with the current meds.

In summary, most people are in emergency services, public safety, or healthcare because they want to help others. And most of those people know that they need to do the right things in order to help others. Most of us also have a relatively low BS tolerance. What does that mean? Procedures and policies that don’t work get ignored or there’s malicious compliance. That undermines respect for the organization, the leadership, and the procedures and policies that DO work. Further, when the bad thing happens (and it will), the lawyers have a field day. Even if the actions (or inactions) of these providers didn’t cause the bad outcome, there’s enough doubt to give a jury (or an insurance company) reason to question what really happened. It’s also a huge hit to the department’s reputation and the profession’s reputation as a whole.

For the leaders (whether formal or informal) in organizations, take a good look at your policies, procedures, and processes. See if they reflect reality. See how much of a “BS factor” there is to each and every one. Revise or even remove the ones that don’t make sense. And when you finally get to something that’s workable, hold people to account. Even if there’s not a negative outcome. Especially if there’s not a negative outcome. As we know, “just culture” doesn’t look at the outcome, it looks beyond that. On that note, when you bring someone in to talk about a violation, ask how and why it happened. Don’t immediately assume malicious or malevolent intent. The explanation might actually solve an underlying problem that you were never aware of. If it’s a department fault, fix it. If it’s an individual fault, remediate them or use the appropriate discipline. A policy that’s unenforced or not applied is a policy that a plaintiff’s lawyer will have a field day with.

As for those of us who aren’t in a leadership role, we need to let leadership know when something doesn’t work. Better yet, have a proposed solution. Hopefully, you’re in an organization that will take action on your concerns – whether making changes or providing insight as to how/why the changes can’t happen — or the current system actually works.

If you’ve made it this far, thanks. If I can be of help to you or your organization, I do make house (or station) calls.

Earlier this week, I watched a great documentary movie about the volunteer fire (and EMS) service called Odd Hours, No Pay, Cool Hat. The movie does a great job illustrating the various cultures of volunteer emergency services throughout the country as well as people’s motivation to volunteer and why they remain. As a volunteer myself (almost 19 years now), I saw a lot of myself in the movie and recognized some of the people I’ve worked with, even if the names and locations weren’t the same ones in Texas that I know.

Then, I looked at one of the departments they highlighted. Said department (which is NOT in a poor or rural backwater) wants their members to do a weekly night shift and a 24 hour Saturday shift every 4th week. That kind of schedule isn’t a volunteer schedule. It’s a part-time employee schedule. While this department was along the mid-Atlantic Eastern Seaboard, I’ve seen several volunteer fire and EMS departments in Texas that operate along the same scheduling concept. And the department that I spoke to in Texas seemed genuinely offended that I wasn’t able to meet their 48 hours per month commitment via a twelve hour shift weekly as opposed to my suggestion that I could come for two 24 hour shifts on the weekend. Apparently, at least there, they had a surplus of Texas licensed paramedics willing to work for free.

What I routinely see is the self-fulfilling prophecy that “we can’t get volunteers.” The truth is that volunteers are out there. The truth also remains that not everyone has the time, temperament, or inclination to basically work a part time job — especially with the added burdens of attending monthly meetings, fundraisers, committee meetings, and various mandatory trainings only offered at certain times. Even more so if you’re driving a way because of limited (or no) opportunities to function as an EMS provider or firefighter nearby.

Even the “hiring” process at volunteer organizations can be haphazard. People often don’t know that an organization exists, let alone is looking for volunteers. And attending a few “business meetings” to be voted in as a member, whether it’s a pro forma vote or a popularity contest undermines the notion that a volunteer department is truly staffed by “unpaid professionals.” Attending some department’s monthly meetings also demolishes that notion as you witness the lack of accountability, personal politics, self dealing, sense of entitlement, and rampant spending on pet projects. Thankfully, these are not issues at either of my current departments (one combination department and one entirely volunteer organization), but the stories ring true nationwide when my volunteer (and former volunteer) fire and EMS friends discuss their experiences. And those are just the issues that arise at the business meetings — not even addressing training, equipment, operations, and the other day to day issues that will either cause people to remain long term members or rage quit when the final straw breaks the camel’s back.

Volunteer fire and EMS is often its own worst enemy as it lowers standards, engages in petty politics, and creates a self-fulfilling prophecy of not being able to find volunteers. Oftentimes, they can’t fund volunteers because people don’t know they’re looking. Or if people do express an interest in volunteering, they are turned away because the volunteer organization only has one way to use them, whether it’s the failing model of the fixed duty calendar (see also: You’re working as a part time employee at this point and you should be paid as such.) or the idea that one must be all things to the department to be of any use. (See also: Most volunteer fire departments that turn away EMS-driven individuals. Pro-tip: Giving an “EMS-only” EMT or paramedic the keys to a squad truck means those who want to fight fire can do exactly that.) And of course, once a motivated member makes it through the malarkey and is still motivated, they’re all too often met with the conundrum of command staff playing the martyr, yet who are unwilling to delegate anything. The idea that new members need to pay their dues seems in direct contradiction to the martyr mindset of many chiefs and officers who simultaneously bemoan that the younger generation doesn’t want to help while also retaining their positions and duties even longer than some United States Senators. (For example, take a look at the interlocking boards of most of the EMS organizations and “stakeholder” panels where board members and stakeholders haven’t been on an ambulance or fire apparatus since there was a BioPhone and MAST trousers.)

Until we stop chasing the perfect volunteer and take what’s available to us, we’re doomed to the volunteer fire and EMS model being a historical relic that will, at best, limp along only because of the unwillingness of local governments to adequately fund emergency services. While we still have a volunteer or combination model for emergency services (by the way, there are reserve police officers too, even in large agencies), we have to either adapt our organization to reality or adapt the prospective volunteers to the organization. The former will be easier, no matter what the old guy in the back of the meeting says.

Otherwise, the stagnation will continue with the duty roster becoming more and more empty and no one wanting to “put up with that BS” to “work for free.”