Licensed Texas attorney. Licensed Texas paramedic. Unlicensed BBQ critic.

Licensed Texas attorney. Licensed Texas paramedic. Unlicensed BBQ critic. And yes, I went to law school first. Got to learn how to chase the ambulance before you can drive it. Politically incorrect infidel who's very conservative. . Oh, and also a big fan of country music, firearms, and, as of late, cars.

What We Really Are

Posted on January 29, 2016 Written by

I see a lot of people in EMS who want to be heroes.  I see a lot of people in EMS who consider us part of the public safety family.  Occasionally, there’s some heroism in EMS.  And yes, in many places, EMTs and paramedics are part of the public safety team. I also hear the term life-saving bounced around.  I can count on one hand the number of EMS calls where a life was immediately saved by EMS interventions.  Lives prolonged?  Yes.  Lives made better? Yes.  Lives saved immediately?  It’s a rare occasion.

I have a real concern, though.  None of those reflect the day-to-day reality of EMS.  In my opinion, after a few years in this field in a variety of settings, we rarely get to be heroes.  In fact, if we’re at the point of heroism, something’s likely to have gone really wrong in the course of the call. What we really do is deliver unscheduled out-of-hospital medicine.  Our definition of “emergency” often varies from the patient’s definition, but the God’s honest truth is that we’re here for our patients.  Period.

Over the last couple of days, I’ve been pretty dismayed by some posts I’ve seen in EMS social media groups, whether by new EMS students or experienced providers.  I’ve seen posts advocating “punitive medicine” like ammonia caps and dropping the patient’s hand on their face to determine if the patient is “faking” a seizure.  I’ve seen other posts asking how to identify “drug seeking” patients so that a provider can hold back pain relief.  I’ve seen posts advocating that EMS providers be allowed to decide who gets to go to the emergency department. And I’ve seen posts by supposedly experienced paramedics advocating “just taking the patient to the hospital” rather than performing a complete assessment and providing treatment all because the hospital is close.

I get all of these complaints.  I really do.  We’ve all been on the shift where the calls keep coming and it seems like no one really has a supposedly legitimate emergency.  I’ve complained.  I’ve griped to my colleagues. And I try not to let it impact what I’m doing as a medic.

The reality is that we may be public safety heroes who save lives — occasionally.  But what we truly always are is professional caregivers.  Part of the obligation that you have is to suspend your judgment of the patient in order to CARE for them.  Even the most malevolent, challenging psychiatric “frequent flyer” has issues that we’re not going to be able to understand, much less fix as EMS providers.  Our duty is to assess the patient, provide care as we’re educated to, and get them to an appropriate destination to address their concerns.  When we start embracing the care aspect of the job more, we’re going to have less burnout, better outcomes, and probably some happier EMS professionals.  Until that point occurs, I’m concerned — because I’m seeing what people think is acceptable.  Ask yourself if that’s how you’d want your family treated or if you’d be proud for the local news media to showcase your last call.

It’s time for all of us in EMS to take a look in the mirror and see what we’re becoming.  I, for one, am not sure that this what any of us should accept or condone.  We can do better.  I know because I’ve seen us do better.

Filed Under: EMS, EMS 2.0, Rants

You Don’t Understand What We Do

Posted on January 26, 2016 Written by

One of the recurring things I see with EMS memes and t-shirts is the theme that “you don’t understand what we do.”  This sentiment is usually expressed along with some gory or chaotic EMS scene intended to show just how hard and heroic it is to be an EMT or a paramedic.  Funny how these scenes never show the more mundane dialysis transfer or posting the ambulance at an intersection.  But I digress.  Being a medic, I understand the realities of EMS, especially the unpredictability, the inability to know what will happen next, and yes, even the occasional chaos.

Last night, a good friend of mine who’s been around EMS for a while told me about an encounter they had with an older medic they occasionally work with.  My friend was explaining and sharing an article about the Folstein Mini-Mental Status Exam, its applicability to EMS, and how the standard chart notation of “A&OX4” for alert and oriented times four is rather insufficient, especially in the legal setting as it is conclusory and often lacks further context or explanation in the medic’s chart. The other medic, let’s call him T-Rex, because he approaches dinosaur level knowledge, argues that he’s been to court multiple times and no attorney has ever challenged him.

Let’s stop right there. Putting my lawyer hat back on, I can, with a pretty high degree of certainty, tell you why no attorney has challenged T-Rex on his documentation.  The documentation of “A&OX4” is not relevant to what the attorney is asking about. I’ll further surmise that, fortunately for him, he wasn’t the defendant a lawsuit in which the patient’s present mental capacity was a key part of the plaintiff’s claim.  In such a case, I can assure you that the questioning from opposing counsel would have taken a much different tone.  Additionally, the questions that the lawyer asked would have most likely been guided by an expert witness or two with knowledge of EMS.  The experience of being examined or deposed by opposing counsel is rarely a fun experience, even when the lawyer comes across as being friendly.  Nay, especially when the lawyer comes across being friendly.  The probing nature of the methodical examination and questioning of each and every aspect of everything you did on that call is the mental version of a simultaneous colonoscopy and root canal, both of which are occurring without the benefit of pain management or sedation.

So, my dear EMS friends, I ask you this.  Don’t presume to understand what a lawyer does, why they do it, or how they do it.  Having had the benefit of law school, I can assure you it’s as foreign of an experience to an EMS provider as the work of an EMS provider is to an attorney.  We just don’t have “cool” t-shirts or memes to tell you how awesome it is to be an attorney or how you don’t understand what an attorney does.  Maybe I should get some t-shirts printed up with Tom Cruise saying, “I want the truth!”

Until the t-shirts get printed, here’s hoping that each of you never have to find out exactly what it is that a lawyer does or how we think.

Filed Under: EMS, EMS Legal, Law

Opining on Protocols

Posted on January 22, 2016 Written by

As Bill O’Reilly says, if you must opine, keep it pithy.  I may not be pithy, but I must opine.  Lately, I’ve noticed a recurring trend on EMS social media when discussing protocols.  Namely, people are convinced that deviating from protocol makes you immediate prey and fodder for attorneys.  Well, that’s simply not true.

Here’s some good news.  First, most attorneys aren’t that interested or knowledgeable about EMS and what we do.  Second, while deviating from your protocols may well get you in trouble with your medical director and/or your bosses, it’s not going to make you automatically subject to a lawsuit.

Let’s discuss that a bit further.  Most claims against EMS for a bad outcome are going to be based on negligence.  I’ve discussed negligence before, but as a reminder, the four elements are a duty to the patient, a breach of that duty, causation of harm, and damages.  So, in order to prove a negligence claim based on a breach of protocol, one must first prove that deviating from protocol breached the duty to the patient.  In other words, the plaintiff is going to have to prove that the protocols represent the current standard of care.  In many cases, many EMS systems have outdated protocols that do not represent the standard of care.  For example, look how many EMS systems still backboard the majority of trauma patients or require high-flow oxygen for all patients.  In the case of high-flow oxygen for cardiac and stroke patients, the current science in fact reflects that high-flow oxygen actually harms patients. Next, the plaintiff will have to prove that the deviation from protocol caused harm to the patient and that the harm caused damages.  That’s a high burden to overcome.  In other words, the plaintiff is going to have to prove that what you did or didn’t do was the reason there’s a bad outcome.  Especially in critical or high acuity patients who had a bad outcome (IE, death), there’s often an argument to be made that, no matter what EMS or other medical providers did, the patient might have died regardless.  The reality is that we just aren’t going to get every patient back.

And let’s consider one other thing about protocols. Sometimes protocols are blatantly wrong and following them is just as wrong.  Let’s pretend that your protocols suggest you administer a clearly incorrect dose of medicine.  Blindly following them does not shield you from liability.  As a trained medical professional (which is what we’re all striving to be), you have an obligation to clarify and/or refuse to follow a clearly wrong order.  The “just following orders” defense went out with the Nuremberg trials at the end of World War II and remains just as legally and morally invalid as it was then.  If EMS providers want to be considered as the professionals we should be, then we can’t hide behind the doctors’ lab coats when we’re practicing medicine that is clearly wrong and/or harmful.

Of course, nothing here constitutes legal advice.  I’m just trying to clarify and educate here.  If you’re that worried about the attorney boogeyman, your time and money would be better spent on buying EMS professional liability insurance and/or consulting with a lawyer admitted to practice in your state.  Sadly, I’m afraid that some of the people most worried about the legal boogeyman would rather spend their time repeating legal myths and dogma they heard third or fourth hand in a war story during their initial EMT class’s medical legal lecture.

In conclusion, the law is a complex and nuanced topic that is dependent on the statutes and case law of the particular jurisdiction as well as the facts of the case.  That’s why those who’ve attended their one mandatory medical legal class have absolute certainty in their wrong answer and why attorneys with three years of law school after four years of undergraduate education say, “It depends.”

Filed Under: EMS, EMS Education, EMS Legal, Law

About Nightwatch

Posted on January 17, 2016 Written by

Earlier today, I was reading a post on Facebook from Titus Tero, one of the paramedics featured on A&E’s reality show Nightwatch.  I’ve watched the show several times.  The paramedic in me occasionally winces at some of the clinical and operational aspects of the show.  Of course, like a color commentator on a football game being telecast, I’m always happy to critique the events play-by-play.  That’s just human nature and doubly so for an attorney and paramedic.

However, there’s one thing I can’t fault about Nightwatch and the crews they follow around with a camera.  Namely, they treat every patient with dignity, respect, and dare I even say, a bit of love.  I’ve always believed and often say that the overwhelming majority of our patients don’t know how good our care is (or isn’t).  However, every patient is perfectly capable of figuring out if their medic(s) gave a darn about them.  I’d say the same is true of the overwhelming majority of viewers of Nightwatch.  They don’t know whether New Orleans EMS is a great system or not.  They don’t know the current science on spinal motion restriction nor the current use of CPAP devices.  What they have most likely figured out from watching Nightwatch is that if you call 911, you’ll most likely get caring medical professionals.  That’s the legacy that Johnny and Roy left with my generation from Emergency and EMS and the fire service have reaped the benefits ever since.

So, to the ladies and gentlemen of Nightwatch, I thank you for faithfully representing the EMS profession with the care and passion that we all strive to deliver daily.  The truth be told, I’m not 100% sure I could always live up to those standards every day, every time, especially with a TV camera following me.  You’ve done our profession a great service.

Filed Under: EMS

At the very least.

Posted on January 5, 2016 Written by

I was talking with a local college EMS faculty member about determining the right hospital choice for the right patients.  She rightly pointed out that emergency physicians routinely deal with patients who are brought to the hospital by themselves, family, or friends.

Here’s my premise about what we do as EMS professionals, especially as it relates to taking the right patient to the right hospitals for the right conditions:  We need to be doing a better job for our patients than transport via private vehicle.

Whether it’s assessment, destination determination, treatment, patient advocacy, or patient comfort, our goal needs to be that we’ve done a better job, each and every time, than the patient would have from getting a ride from family or a friend.

It’s arguably a low standard, but I’d argue that we aren’t hitting that standard all of the time.  And until we do, it’s hard to justify the existence of EMS. Whether it’s the bean counters who balk at the price, the “policy experts” who balk at the outcomes, or the customer satisfaction gurus who do the patient surveys, EMS is doomed until we can prove, consistently, that patients do better with EMS than without.

Filed Under: EMS, EMS 2.0, EMS Education

Why is learning bad?

Posted on December 30, 2015 Written by

I’ve been blogging a bit more lately and engaging myself a bit more in the EMS world, both locally and in social media. One continuing theme I notice in EMS is that there’s a sizable number of EMS providers who actively discount and discourage education.

Whether it’s derisive comments about being “book smart” versus “street smart,” comments discounting the importance of an entry level exam to determine a safe level of minimal competency, or the constant demands to water down the curriculum because we “don’t need to know it,” the reality is that the rampant anti-intellectualism in EMS holds us back from professional development, respect, and ultimately a sustainable career path as a prehospital professional. Additionally, our rampant discounting of knowledge and education means that we’ve placed the EMS profession at the mercy of others to determine our destiny.  Bluntly, look at the number of non-EMS types on almost any committee discussing EMS, whether regulations, education, or practice.  You’ll never see that ratio of non-professionals in any other health care profession. The solution is simple.  Our profession has to embrace both the academic pursuit of prehospital care and developing a professional identity (and knowledge base) of what EMS is.

The extreme focus on skills to the detriment of a core foundation of knowledge dooms EMS to being, at best, a skilled trade.  There’s nothing wrong with a skilled trade.  I know plumbers and air conditioning techs who make more than many attorneys I know.  But I also know that there aren’t skilled trades in healthcare.  EMS has to have a professional identity, which begins with a core set of knowledge.

When we embrace that there is a core set of intellectual knowledge to be an EMS professional, we will find that we control our destiny as a profession. Whether the future in EMS is community paramedicine, critical care, tactical casualty care, or even something we haven’t yet identified, EMS can’t grow or move forward until we realize, recognize, and embrace that there have to be minimal standards to entry into the profession and that there’s a core base of knowledge in EMS, which should ideally be developed and guarded by EMS professionals. Until then, we’re just complaining about the test being too hard, wondering why the average EMT could make as much money at McDonald’s, and wondering why so many good medics leave EMS for another field.

Filed Under: EMS, EMS 2.0, EMS Education

No matter how you look at it.

Posted on December 27, 2015 Written by

No matter how you look at it, no matter how you say otherwise, the reality is that emergency medical services, whether at the basic life support level or the advanced life support level is, plain and simple, the practice of medicine.

Those of us with a passion for EMS, myself included, regularly dream of what EMS can (and should) be and bemoan our current state.  Things I regularly despair over include the lack of professional development, professional identity, and pursuit of excellence.  You know, many of the same traits that other health care professions do a much better job of than EMS does.

Sadly, in my mind, the reason that EMS continues to lag behind the rest of the healthcare professions is that we’ve made it too easy to become an EMS provider. The reality is that most health care education programs are degree based and have college entrance requirements at a minimum. EMS – not so much.  We all know how hard it is to get into medical school or even nursing school.  EMS seems to be the exact opposite.  The entrance exam for most EMT programs is a check that clears the bank.  The entrance requirements for many paramedic programs are not much more stringent.  But that’s to be expected, we define EMT and paramedic by a set of skills rather than a core foundation of knowledge.

So, should it really surprise us that we haven’t progressed any further yet?  We’re allowing people who are unprepared for postsecondary education to practice medicine, albeit with a limited scope. To me, it’s little wonder that dogma, anti-intellectualism, and the “meet minimal standards” mindsets pervade so many EMS systems.  It’s little wonder that in many (note that I didn’t say all) fire-based EMS systems, the EMS side of the operation is seen as punishment or an assignment to be escaped from eventually.

Heck, to me, the real wonder is why some of us continue to engage in the quixotic pursuit of making EMS a respectable, recognized practice of medicine.

Filed Under: EMS, EMS 2.0, EMS Education

System Abuse. Yet again.

Posted on December 21, 2015 Written by

System abuse.  That’s a term we commonly hear in EMS.  And as soon as we start talking about system abuse, the talk invariably turns to EMS providers’ favorite solution for system abusers.  Namely, the idea that EMS providers should be able to refuse transport to system abusers.

First of all, what constitutes a system abuser?  We all know at least one of these creatures by name in our local service area. Yet, in my eleven years in EMS, I’ve yet to hear an agreed-upon definition of system abuse.  It’s like the definition that former Supreme Court Justice Potter Stewart created for pornography — namely, that he knew it when he saw it.

Next, failing to provide treatment/transport to a so-called system abuser is a recipe fraught with peril.  EMS medical directors, as a matter of risk management, have to write their protocols and policies to mitigate the risk of a poor decision being made by the worst provider in the EMS system.    We’ve all seen or heard about “that guy” in our local system.  The guy who missed a STEMI.  The guy who doesn’t manage pain.  The guy who took a trauma patient to a local community hospital.  Bluntly, when the doctor (and the lawyers) think about it, the safest, easiest, least risky decision is to encourage every crew to transport (or at least offer to transport) every patient every time.

The average EMS provider has no idea of what they don’t know.  Most EMS education programs excel at creating the impression that, by teaching a set of skills to “fix” some very acute medical emergencies, the average EMS provider is “doing everything that a doctor does.” After any period of time on the street working as an EMS provider and seeing the reality of our calls, we find our assessment skills in particular make us ill-suited for the reality of modern EMS — namely, the unscheduled delivery of primary care, urgent care, and the occasional emergency care.

I don’t have a solution for system abuse.  However, I can tell you where the solution starts, at least in my eyes.  To comprehensively address EMS system abuse, EMS providers need to work with EMS physician medical directors to develop a local protocol defining system abuse, providing alternative dispositions for these patients, and providing comprehensive medical oversight to mitigate the risk of deviating from the current accepted paradigm of taking every patient to the hospital emergency department.

My cynical side says that instead, one of two things will happen.  One, we’ll just keep complaining and wishing that we had the ability to turn away patients.  Two, some vendor will come up with some technological “solution” that just makes things more of a hassle than to just provide a ride to the ER.

As much as I love the practice of prehospital medicine, I sometimes think that the worst enemy of EMS is the average EMS provider. The solution to system abuse and almost every other EMS challenge is to raise the standard of what constitutes the average provider.

Filed Under: EMS, EMS Education, EMS Legal

Dear EMT Student

Posted on December 18, 2015 Written by

Early this morning, I brought my father to the ER.  He’s getting up there in years and he’s pretty sick.  You came into the room with several of the nurses.  Having remembered my ER clinicals, I slid over and introduced myself to you and told you what was going on with dad.  With his congestive heart failure acting up, I suggested that you might want to listen to his lungs.  You told me that you had “already gotten all of your lung sounds.”  Apparently, I should’ve caught onto that from the fact that you weren’t even carrying or wearing a stethoscope.  You never introduced yourself to me, my father, or anyone else in the room.  You never laid hands on the patient, did an assessment, or performed any skills.  However, I did see you spending most of the rest of the night sitting at the nurses station cutting up with the unit clerk and the techs.

Congratulations, kid!  You’ve succeeded. You’ve illustrated so much of what’s wrong with EMS.  You came to a clinical unprepared.  You showed me through both your actions and attitude that you’re merely marking time and there to get the very minimum done.  You showed a clear lack of interest in furthering your knowledge above and beyond the very minimum entry level of one of the most minimal entry level jobs in healthcare.  And most importantly, you’ve confirmed to me and probably a good chunk of the hospital staff all of the rumors about EMS and EMS students in particular.

You’ve done a great job of harming our profession.  I only have two hopes for you. One, you hopefully get with the program before you end up harming or killing someone with your obvious lack of interest in medical care. In the alternative, I hope the National Registry exam does its job in keeping out the clearly incompetent.

And by the way, for the record, you’d have never started a clinical with me as your preceptor.  Your stethoscope is a required part of your uniform at your program.  You’d have been sent home with an explanation of why; I’d have notified your education program; and I’d have told you to reschedule.

When we allow students like you to progress, all we do is continue to shortchange our profession and retard the growth of EMS.  To my fellow EMS educators, it’s time to abandon “no medic left behind” and start holding students accountable.

Filed Under: EMS, EMS Education, Rants

Some random observations on what we do

Posted on December 16, 2015 Written by

I was having a discussion with one of my favorite younger medics.  He’s brilliant; he’s got a mastery of the science; he’s just convinced he’s right and won’t always let you forget it.  (Sound like anyone you know?)

We reached a couple of brilliant conclusions.

  1. With the current state of EMS education in anatomy, physiology, and pharmacology, I think it’s eminently reasonable to expect entry level medics to have mastery of the bare minimums of knowledge, particularly relating to medications and expand and grown their knowledge base through continuing education.  Of course, this means that continuing education becomes just that, rather than a biennial repeat of topics you already knew about.
  2. EMS won’t be fixed with one big solution. It’s going to be fixed one medic at a time.  In other words, if you aren’t mentoring or being mentored by a colleague, why not?
  3. Two of the most underrecognized failings of the average EMS provider are that we don’t understand the long term effects of our therapies nor do we ensure that the right patients get to the right hospitals.

 

Filed Under: EMS, EMS 2.0, EMS Education
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