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.

Couple of book reviews

Posted on March 30, 2015 Written by

Apologies for the lack of posts lately.  Between a massive contract at the “real” job and having a ton going on in my offline EMS and personal lives, I’ve given the blog a bit less attention than it should have.

However, I’ve recently added several books to my EMS library that I believe the thinking medic should own.

The first is called Avoiding Common Prehospital Errors.  It’s a collection of short (2-4 pages) articles about various aspects of EMS care as written by various physicians, nurses, and EMS providers.  For the average EMS provider, especially those in the average EMS system, it’s a game changing book.  The book contains most of the recent science (published in 2013) out there and more importantly, each article is thoroughly cited with even more references.  If you’re looking to institute evidence-based medicine in your EMS practice, the book, with a few exceptions, does an excellent job of advancing science as opposed to dogma. As such, when the contributors share bad medicine in a few instances (naloxone for altered mental status and a slight dose of “backboard everyone” paranoia), these instances stick out like a sore thumb.  I still highly recommend it.

Virtually everyone in EMS has, at one point or another, had a field guide or pocket guide.  With the rise of smart phones, these are going the way of the dodo bird.  However, one field guide still stands out.  I cannot help but recommend Medic’s Little Helper.  While the book is Canadian, and as such, contains some metric measurements that US EMS providers don’t use, especially for blood glucose levels, it’s a thorough reference that covers a variety of topics in EMS from the most basic reminders all the way to the critical care arena.  It barely fits in the pocket of cargo pants, but it’s a useful companion to have.  Also, highly recommended.

Filed Under: EMS, EMS Education

When you’re managing risk….

Posted on March 2, 2015 Written by

After seeing some of the less stellar EMS providers out there, I can certainly understand why EMS systems and physician medical directors engage in risk management.  I would too and I encourage it.  EMS providers are great at reacting to medical emergencies and physicians, by and large, are great at medicine.  However, in my humble (ok, laugh) opinion, the professionals who know how to manage and mitigate risk are attorneys.

Several EMS systems attempt to manage and mitigate risk by creating an extensive field training/credentialing/clearance to practice model.  The lawyer in me is skeptical.  Allow me to throw out some legal analysis that I believe illustrates some additional risks that this paradigm creates.

1) Whether we like the National Registry or not, we can all agree that they’ve spent a great deal of time, money, and effort in producing a test that can be validated and defended. How many other organizations can defend their testing processes?  How many EMS systems can defend their field training processes?  I can assure you that this is an employment and/or civil rights case waiting to happen, particularly if adverse action is taken and you can show some discrepancies in how some people were treated versus others.

2) As we all hopefully remember from medical-legal 101, the standard of care is “what would a reasonable and prudent provider of similar education and experience do?” We also know, that generally speaking, Good Samaritan laws as well as other state-specific statutes often hold EMS providers to a willful conduct or gross negligence standard.  Assuming that you’ve created this extensive process to authorize a provider to function in your EMS system, I believe that you may have created a system where what might be ordinary negligence could potentially be considered gross negligence since they went through some extensive process that could be argued to hold them to a higher standard of care.

3) I think there’s potentially increased liability for the EMS system and the physician medical director.  Imagine this one well-placed question from a plaintiff’s attorney.  “So, you had this medic for X number of months.  And Medic So-And-So still made an error in calculating the drug dose.  What exactly was your system and FTO Such-And-Such doing during these X months of field training?”

4) While anecdote is neither law nor science, I could very easily imagine a case where a state licensed advanced provider who is not locally “credentialed” could be in a time-sensitive situation with a bad outcome. Imagine a pediatric seizure patient who did not receive benzodiazepines because the provider was neither equipped nor authorized to provide advanced care.  I can virtually guarantee that this family will be sympathetic plaintiffs and they will be able to find an expert witness who will testify that their child would not have suffered an anoxic brain injury had the first arriving provider been able to administer the proper medication(s).

Do I think that EMS systems should turn providers loose on day one?  Absolutely not.  I also believe that the field training process should focus on operationally integrating a provider into the local EMS system and that the appropriate way to develop providers medically is through the quality improvement and continuing education processes.  But then, how many EMS systems have developed these processes?

I believe a field training process needs to exist.  There are several strong, validated programs out there, most notably the EMS FTEP program out there.  Why reinvent the wheel when you don’t have to?  Combining a strong, proven FTO process with a rigorous QA/QI process and ample opportunities for continuing education and professional development is my recommendation for real EMS risk management.

Filed Under: EMS, EMS Legal Tagged: , ,

My Sermon to You

Posted on February 14, 2015 Written by

I’m not the world’s most religious guy.  But I just awarded myself a new title. I’ve accepted ordination as a reverend in the EMS Church of the Painful Truth.  And for my fellow followers of the gospel of the truth that EMS is the practice of medicine, I deliver to you my first sermon.

I direct my preaching at the wayward masses.  Because, after all, it’s the sinners who need salvation, not the choir.

Here’s who and what holds EMS and EMS education back.  Students who consistently fail to take responsibility for their own learning; the fictional belief that some specific study guide or app will magically allow them to pass NREMT; the belief that the NREMT exam is difficult; low entry standards for any EMS education program; and an army of mindless drones bleating along about how “you can do it.” And of course, the belief that the test shouldn’t matter so long as you can do skills and you want to be in EMS. I am fully expecting to be called a meanie, unsupportive, a paragod, and probably several other names. Here’s one thing though. I’ve achieved my EMS certification. The secret? A little bit of intelligence, some common sense, and a four letter word that’s forbidden to so many unsuccessful EMS candidates – WORK.

If EMS is that important to you and you truly feel called to deliver medicine at all hours of the day or night, then EMS should be important enough to master, much pass an entry level test designed to measure minimal competence to practice your craft safely.

No more excuses.  Join the EMS Church of the Painful Truth.  All you have to lose is your dogma and all you have to gain is the knowledge that, contrary to what the rest of our craft says, you are a medical professional.  And the Kool-Aide is safe to drink.

Filed Under: EMS, EMS Education, Rants

In Case You Missed It….

Posted on February 12, 2015 Written by

I’m now on EMS1 as well.   Talking about compassion.  Shocking for a lawyer!

Filed Under: EMS, EMS 2.0

Medical Practice By Cliche

Posted on January 30, 2015 Written by

One of my biggest complaints in EMS education and practice is that too many providers take clichés from t-shirts and turn them into the dogma of EMS practice.

Two of these overused sayings are similar.  “BLS before ALS” and “EMTs save paramedics.”  And they’re two sayings that when the President appoints me “EMS Czar,” I will ban with the severe penalty of taking away your collection of EMS t-shirts and Galls’ catalogs.

My biggest concern is that many of the people who repeat these saying the loudest (because we all know that in EMS, loud=winning) are those who are BLS providers who don’t have ALS education.  This is the equivalent of me spouting off that paramedics save physicians, even though I only have a vague idea of what happens in medical school or graduate medical education.

The realities are this.  These cliche sayings are nothing more than feel-good t-shirt sayings designed to boost the ego of entry-level EMS providers.  Furthermore, even a marginally competent paramedic doesn’t differentiate between BLS and ALS skills and assessment.  They synthesize the knowledge they have along with their experience to create a holistic view of the patient and treat the patient as such.  In the actual world, many patients, especially those with medical complaints require the assessment of a paramedic level provider, if not paramedic level interventions.

I fully acknowledge that there are some excellent EMT-level providers out there who are the exception to my semi-rant.  These EMTs are primarily found in EMS systems where there’s an extensive field training and continuing education process that mandates a level of independent BLS practice.  In other words, becoming a truly independent BLS provider ready to assume responsibility for patient care requires much more than what currently counts for initial EMT education.

But the sad reality in much of the EMS universe is that EMT education consists of little more than showing prepackaged PowerPoints, war stories, and some level of minimal competency.  With that current paradigm, there’s only a small subset of patients who would benefit from BLS treatment without at least an assessment from a paramedic level assessment.

Ultimately, like much of medicine, and for EMS in particular, you don’t know what you don’t know.  If you want to be trusted, the best recommendation I can give is to never be satisfied with minimal competence in the entry level of emergency medicine.  Quit worrying about justifying what is really an entry level skill set — learn and grow to advance your knowledge, whether formally through a paramedic certification, or at least through formal and informal continuing education.

As most of y’all know, I tend towards blunt.  Medicine is about helping people.  And you can’t help many people, including your partner, if you merely meet minimum standards in the minimum level of certification to staff an ambulance.  And this truth remains plainly evident no matter how much you cite cliches and stories that your instructor told you.

Reality is — we’re a team.  We all have a role to play and much of the role of the BLS provider is to assist the ALS provider.

Filed Under: EMS, EMS 2.0, EMS Education, Rants

About That License

Posted on January 27, 2015 Written by

I get it.  Becoming an EMT is a big accomplishment for many, even including me years ago.  It was pretty cool to know about things and do things that the “rest of us” don’t get to do.  And the same is true if and when you make the jump to paramedic.  You might even get some neat t-shirts to flaunt that you’re an EMT or a paramedic — and especially proud of it.  The really neat part is that your state gives you a piece of paper or plastic that identifies you as an EMT or paramedic, which means you’re “officially” able to do EMS things.

I have another card in my wallet as well.  It’s my card from the State Bar of Texas that identifies me as a Texas attorney.  It means that I get to do things that others can’t do.  It’s a bit of a long road to get one of these cards.  It takes a four year undergraduate degree followed by three years of law school.  Then, the licensing exam.  It’s a two and a half day exam, given only twice a year.  And it means I get to give legal advice and represent (and counsel) clients about the law.   When you learn the law, you learn that few things are in a vacuum.  A statute alone means very little.  You need to look at the definitions that might be found in other places.  You need to look for relevant court cases applying the statute.  You need to look for regulations implementing that statute. And then you figure out how all of these things apply to the facts of your client’s case.

So, when as an EMT or paramedic with the benefit of a four hour medical legal lecture that was read by another EMT or paramedic who’s not an attorney and the slides were prepared by the textbook feels that they know the law enough to read a statute back to me and claim that’s what the law is, I do get a bit offended.  In my world, that’s the same as some attorney who’s not a paramedic hooking someone up to an IV because they saw a YouTube video.   Just like there’s more to being an EMT or paramedic than knowing how to do some random skill(s), there’s more to being an attorney than reading back a statute.  That’s why it takes a while to become a lawyer.

And that, my friends, is why I get offended when some EMT feels that they know what I know based solely on reading a statute and misinforming their colleagues.

In conclusion, I’m incredibly proud to be trusted by my state as both a paramedic and an attorney.  And I will continue to protect both of my professional identities from those who haven’t been admitted to practice in either profession.

Filed Under: EMS, EMS Education, EMS Legal, Rants

If We’re Truly Doing Everything Doctors Do, But At 80 Miles An Hour

Posted on January 20, 2015 Written by

Look around the EMS social media world for any period of time and you’ll see a bunch of worn-out clichés.  One of the more popular ones is “We do everything a doctor does, but at 80 miles an hour.”

Ok.  I’ll accept your cliché.  And being a betting type, I’ll raise you one.  Let’s assume and accept that we, as EMS providers, are practicing medicine — because we are.  And we’re even diagnosing patients.  (Let that one sink in for a moment.  I’ll wait.)

Ok, you’re back.  So, yes, we’ve accepted the position that EMS providers are practicing medicine.  That means we’re getting a medical education as well, right?  And said medical education, regardless of how and where it’s delivered, should be at a level above high school, shouldn’t it?

You’re darned right it should be.  As I’ve mentioned in the past, for the paramedic provider, we’re trying to condense the critical parts of a bachelor’s degree, medical school, and an emergency medicine residency into, at best, a two year program.  That means there’s a lot of knowledge coming at students quickly.

Yet, of all of the education programs out there, EMS education seems to operate on the open enrollment model.  Did your check clear?  You too can try to become an EMT or a paramedic.

When we accept students who can’t express themselves in the English language, do simple mathematics, or have a rudimentary knowledge of the basic sciences of biology and chemistry, it should be little surprise that the course completion rates and National Registry exam passage rates are abysmal.  It should be little surprise that EMS students are constantly posting questions about examination and certification processes that could be discovered with a simple Google search. And it should be even less of a surprise that EMS doesn’t receive the recognition and respect that other allied health professions earn.

If we want EMS to be treated as a profession, maybe it’s time to enforce some entrance requirements.  Not everyone gets to be an astronaut or a starting NFL quarterback.  Maybe, just maybe, it’s time to say that you don’t get to play doctor in the back of an ambulance unless you have some minimum academic credentials.

Filed Under: EMS, EMS 2.0, EMS Education, Rants

We make a difference.

Posted on January 5, 2015 Written by

Everyone hears the propaganda about how EMS makes a difference.  Some of it might even be true.  I’ve had a few calls in my career where I’m at least somewhat convinced that having trained EMS providers on scene made some difference for the patient.  A couple of heart attacks, a couple of allergic reactions, and a couple of difficulty breathings remind me of how my partners and I might have saved a life.  Countless hands held, pain meds given, and nausea meds administered remind me of how the “little things” might make more of a difference than management in the administrative offices ever will be able to quantify.

But that’s not the difference I made today.  Today, I made a difference for two of my colleagues.  Between my presence on some EMS Facebook groups and this blog, people know who I am and what I stand for.  Even more importantly, because of the nature of social media, people know who I consider my EMS family.   One colleague, a younger EMT, came to me today and asked me the age-old question about their readiness to advance to paramedic.  We had a good conversation and a few laughs and I hope that at the end, I was some help.  Shortly after that, a paramedic colleague called me with questions about recertifying.

Neither of these calls were a big deal in the grand scheme of things.  But if we, those of us who consider ourselves to be “good” providers, motivated by the right things in emergency medicine, don’t make ourselves available as mentors, resources, or peer support providers, then someone else surely will.   These may be the the Low Information Voters who chant the shopworn phrases of low EMS standards.

So, for those of you who consider yourself to be good medics, you’re not truly a good medic until you’re helping someone else grow and advance.  The only way to grow the numbers of “good” medics is to not give an inch of ground to the “meets minimum standards” team.  And that means making yourself available and approachable to your EMS friends, family, and colleagues.

It’s that important.  Really.

And I couldn’t let this go without thanking a few unnamed physicians, a few people on the old Yahoo Groups, some Austin/Travis County EMS paramedics, and the family I grew into at Harris County ESD-1.  Each of y’all saw something in me, even when I didn’t.  Each mentoring opportunity I have is but a small attempt to pay each of you back.

Filed Under: EMS, EMS 2.0, EMS Education, EMS Legal

Think Nationally. Act Locally.

Posted on December 22, 2014 Written by

There are a lot of new ideas floating around EMS these days.  Compact licensure for EMTs and paramedics just like nurses already have.  Community paramedicine.  New educational standards.  And the list goes on.

Here’s why many of these well-intentioned ideas remain just that — well-intentioned ideas.  Many well-intentioned EMS opinion leaders with well-intentioned ideas have no idea how, or more importantly, where a well-intentioned EMS idea makes into law.

With a few notable exceptions (EMTALA, HIPAA, and CLIA coming to mind immediately), most EMS laws and regulations are creatures of state government.  Overall, emergency medical services are provided at the local level and are regulated by state statutes and administrative rules/regulations.

I see a lot of EMS folks wanting either Congress or some national body (e.g. National Association of State EMS Officials, the National Association of EMTs, or the National Registry of EMTs) to DO SOMETHING, DAMMIT!   I don’t always oppose their ideas (well, except for my healthy dose of skepticism about the so-called “Field EMS Bill.”), but they’re usually barking up the wrong tree.   If you want to make changes to the regulatory framework of EMS, you need to quit looking toward Washington.

As a valued service to my minions and other readers, I’ll tell you the way to fix EMS.  First, learn where your state’s EMS laws are located in statute.  Second, learn where the state administrative regulations regarding EMS can be found and which state agency or agencies create, implement, and enforce these regulations.  Next, learn who your state representative and senator are.  Also, learn who are the senior management in your state’s EMS regulatory entities.  And learn who are the chairs of the legislative committees overseeing EMS laws.

And then, when you want to change how we do EMS, contact those people.  Write, call, email, or better yet see them.  While the results may not be as sexy as going to Washington DC in a hotel doorman’s uniform and getting pictures posted online, the results will be more effective, easier, and might just improve EMS. One state at a time.

Filed Under: EMS, EMS 2.0, EMS Legal, EMS Politics

Negligence for Dummies

Posted on December 9, 2014 Written by

Ok, I’ve adapted this lesson from a Facebook post I’ve made, but I’ve given some thought to explaining some legal concepts that impact EMS and this is my first effort.  Please let me know if this is helpful and if you’d like to see other legal topics explained.

Please understand that while I’m a lawyer, I’m not your lawyer and my explanation will be pretty generic, because the law is going to differ in each state.

There are four elements that are required to prove up a negligence case. You must have all four of these for the plaintiff to win their case. Duty, Breach, Causation, and Damages.

Duty — This means that you owe a responsibility of reasonable care to another while performing an action which could cause harm. Generally speaking, duty does not attach until you are either dispatched to the patient or you assume patient care. Abandonment a separate claim/lawsuit that occurs when you assume patient care and relinquish said care prior to being relieved by a provider of equal or higher training/certification.

Breach — In short, this is breaching the standard of care. Standard of care means what an ordinary, reasonable provider of similar skill and experience would do in a similar situation. While we often discuss state protocols, card courses (CPR, PHTLS, etc), textbooks, and expert witnesses, ultimately, these are all factors and evidence that will be assist the fact-finder in the case (the jury in a jury trial or the judge in a bench trial) establish what the standard of care is.

Causation — In other words, did your acts and/or omissions cause the harm to the plaintiff?

Damages — Was there actual harm that can be quantified to the plaintiff? Did the plaintiff suffer physical, economic, or psychological damages that the trier of fact (whether the jury or the judge) can quantify into monetary damages?

As I mentioned at the beginning, you’ve got to have all four of these elements for the plaintiff to succeed with a claim for negligence.

I’m happy to help explain further, but since I’m not your lawyer and, unless you’re in Texas, I’m not licensed to give legal opinions for you, I’d prefer not to discuss specific case(s) that you might’ve been involved in.

Hope this helps!

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