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.

Some reasoned justifications in favor of jet fuel and flight suits

Posted on August 28, 2014 Written by

In the EMS world, it’s become almost fashionable to question the need for helicopter-based EMS (HEMS).   I personally believe that HEMS has been overutilized on occasion, probably even by me.  (I have a lovely snark-gram from the QA gremlin about that, in fact.)

Having said all of this, I think there are some reasoned, nuanced justifications for HEMS.  Allow me to share a bit, if you will.

1) The “Golden Hour” may not be evidence-based medicine, but there’s definitely a few cases where interventions are time-sensitive.  We can all agree that a multi-system trauma patient or a head injury is best treated in the operating suite, preferably sooner rather than later.  Likewise, there’s a specific window of time for thrombolytic therapy for stroke.  And we definitely know that reperfusion times matter for myocardial infarction.   HEMS adds a speed factor in these cases.

2) Most areas don’t have ground-based critical care transport program.  As such HEMS becomes our default CCT option.  Multiple drips and vent settings on the acutely ill patient, whether encountered on a 911 call or in a transfer to a higher level of care, require critical care transport.  In the vast majority of the country, flight medicine is the default critical care provider. If we want to cut down on HEMS utilization, we’re going to have to provide a ground-based CCT alternative. (And a 40 hour class intended to comply with Medicare regulations governing billing for “specialty care transport” just isn’t going to suffice.)

3) Especially in lower volume EMS systems, HEMS providers are a welcome supplement on critical and special needs populations.  As much as I try to enhance my knowledge and skills, I don’t always get to see enough truly “sick” patients or enough pediatric patients to have the comfort level that I’d like to have.  For providers in less populated areas, the ability to refer the sickest and/or rarest populations of patients to providers with (potentially) more experience and more comfort is not necessarily a bad thing.

4) In some EMS systems, HEMS does bring additional medical interventions and resources to bear.  Blood products and ventilators do provide a benefit in some cases.  In many cases, HEMS operations may have an expanded drug formulary as well.  Some HEMS providers are also using ultrasound and video-assisted intubation. Granted, the cases where a drug or a particular intervention may be truly life-saving and needed “RIGHT NOW” are few and far between, but knowing that the option is there is helpful, again for the sickest of the sick.

HEMS has a poor safety record in many instances. Some HEMS operators engage in questionable marketing practices aimed at both ground providers and the general public.  But until ground EMS steps up its clinical game and offers true critical care medicine, both in terms of provider knowledge and expertise as well as protocols, HEMS will be a needed, if occasionally overutilized, resource in the majority of the USA that’s more than thirty minutes away from truly comprehensive care.

Filed Under: EMS

Ice Buckets

Posted on August 24, 2014 Written by

As a conservative/libertarian type, I’m in favor of individual charity rather than the enforced charity that the IRS collects every April 15.   As such, any giving to charity should be encouraged and celebrated, both for individual self-worth and the good that charitable giving does for society as a whole.

Having said that, though, the Ice Bucket challenge movement is beginning to annoy me.  It’s the “selfie” of charitable giving.  It’s the self-absorbed “look at me” mentality that seems to infest social media.

The twelfth century Jewish philosopher Maimonides proposed the following ladder of giving:

  1. The lowest: Giving begrudgingly and making the recipient feel disgraced or embarrassed.

  2. Giving cheerfully but giving too little.

  3. Giving cheerfully and adequately but only after being asked.

  4. Giving before being asked.

  5. Giving when you do not know who is the individual benefiting, but the recipient knows your identity.

  6. Giving when you know who is the individual benefiting, but the recipient does not know your identity.

  7. Giving when neither the donor nor the recipient is aware of the other’s identity.

  8. The Highest: Giving money, a loan, your time or whatever else it takes to enable an individual to be self-reliant.

I’ll let you judge where the cold water or ice bucket challenges lie on this ladder, especially “calling out” others for the so-called challenge.

I’m no saint and definitely far from perfect, but I have made a different decision for me.  For me, I’ve chosen to give the gift of my time.  I give my time as a paramedic, volunteering in two different EMS systems.  I give my time (usually freely) as an EMS educator, educating our community about the legal issues involved in prehospital care.  And I’ve lost count as to the numbers of times I’ve spent on the phone or computer providing some quick, informal legal advice to medics, firefighters, or cops.   These are the challenges I’ve chosen to answer on my own, with no towel or recorded message required.

Filed Under: EMS, Rants

Core Maxims of EMS

Posted on August 22, 2014 Written by

Here are a few of my core observations and beliefs about EMS.

1) You can never go wrong catering to the lowest common denominator of EMS.  The success of Facebook groups like The Most Interesting Ambulance Crew In The World and t-shirts with themes including cutting clothes off of patients continues to prove this maxim.

2) Until EMS engages itself in political advocacy, our future and agenda will always be subject to the whims of others, whether it’s the nursing lobby, the fire service, or unelected bureaucrats in your state’s health and human services bureaucracy.

3) We’re always looking for the next BIG thing that will advance EMS.  Today’s flavor du jour is “community paramedicine.” As much as I like the idea, I’ve yet to see an easily defined skill set or a knowledge base that’s portable across jurisdictions.

4) As long as we continue to define ourselves by a skill set (e.g. I’m a paramedic, therefore I intubate), we will, at best, remain a vocation.  Honestly, right now, we’re a collection of skills more or less randomly put together as “things that might be useful to know in a medical emergency.”  (Otherwise, how could some universities offer a 2 week program for nurses and physicians to become paramedics?)

5) What passes for our education prepares us for emergency medicine.  What our call volumes is typically represents urgent and primary care with a few actual emergencies on occasion.

6) There’s a joke about leaving two firefighters in a room with a ball bearing and that it would be broken in an hour.  Leave two medics in a room for an hour and there will be a clique of “cool kids” and a rumor mill be going.

7) Patients don’t know how good your medical skills or knowledge are.  They are more than capable of figuring out whether or not you actually care for them.

8) If you’ve seen one EMS system, you’ve seen one EMS system.  At least in the USA, there’s no one ideal model of EMS system or service delivery.  What’s going to work in Presidio, Texas sure isn’t going to work in downtown Seattle.

9) Any EMS service that constantly bangs the PR drum to tell you how progressive they are probably isn’t all that progressive.

10) There are a few EMS systems out there that aren’t worth keeping.  Start over from scratch.  Washington DC. Cough. Washington DC. Cough.

11) The current EMS educational models and examination models give a de facto veto to whichever state has the lowest standards.

12) The most overlooked aspect of an EMS student’s educational experience is their set of clinical rotations.

13) Pain management matters.  Having said that, EMS providers need a non-narcotic option as well.

14) As long as people are willing to accept substandard working conditions, substandard working conditions will exist.  In other words, if you don’t like parking on a street corner for 12+ hours, don’t work there.

15) You cannot build an EMS system without taking care of your medics.  Period.

16) In the overwhelming majority of cases, communities get the EMS system they pay for. A suburban bedroom community that chooses to only have a BLS volunteer service shouldn’t act surprised when a crew isn’t available at 3:00 PM.

17) Until the average EMS provider can use, pronounce, and spell medical terminology with something approximating intelligible English, we shouldn’t be surprised when our healthcare colleagues seem hesitant to trust us with high-risk procedures like intubation and surgical airways.

18) The follow-on to #17 is that we need to prove ourselves competent with our current skill-set in emergency medicine before we can legitimately expect to be entrusted with the expanded scope of practice in community paramedicine or critical care.

19) We’re fooling ourselves when we have providers who want EMS to be able to refuse to treat or transport “low acuity” patients while at the same time parroting the phrase, “We don’t diagnose.”

20) If we truly have a national EMS exam and a common educational standard, reciprocity across state lines should be a virtual given.  Artificial barriers and hurdles established by state licensing entities represent one of the banes of EMS — turf protection.

Final one….

21) Turf protection wars (fire versus other delivery models, private versus public, BLS versus ALS, ad nauseum) will end up proving Ben Franklin’s adage about hanging together rather than hanging separately.

 

Filed Under: EMS, EMS 2.0, EMS Education, EMS Politics

Thinking outside the box on community paramedicine

Posted on August 18, 2014 Written by

I’ve been discussing pain management options with a friend of mine who’s got an anesthesia background prior to entering the EMS world.  We were both bemoaning how EMS doesn’t always excel at managing chronic pain and how our options are, in most cases, limited to one or two opiates.  (And let’s not even talk about how some EMS systems still aren’t medicating abdominal pain.)

Let’s take the average chronic pain patient who calls EMS because of an issue involving breakthrough pain.  Even in the most progressive EMS systems in the US, the average paramedic’s knowledge of chronic pain is limited and their options are even more limited.  I work in a very progressive rural EMS system and my options are, by and large, limited to dosages of Fentanyl, potentially accompanied by Versed for anxiety related to the pain.  In these cases, an opiate, whether or not accompanied by a benzodiazepine, is probably not the best solution long-term for the patient.  Additionally, you’ve basically put the patient in a situation where they’re now going to be transported by EMS, creating an arguably unnecessary EMS and ER bill.

So, there’s got to be a better way, right?  I’m no expert, but here’s my idea.  This might be a perfect model for community paramedicine and/or advanced practice paramedics to get involved.  My paradigm would have these medics working as adjuncts of the local pain management clinic(s).  In a case where the patient is likely experiencing an episode of breakthrough pain related to a chronic pain diagnosis, a community paramedic could be dispatched instead of or in addition to the 911 ambulance response, depending on local dispatch practices.  The community medic would have additional training on managing chronic pain and an expanded scope of practice for such.  In cases where the patient is already working with the local pain management practice, the community medic would be a resource for whatever “safety net” of medications and interventions exist in the patient’s pain management plan for breakthrough pain.  For patients who don’t have a pain management home, a call such as this would be an opportunity for the community medic to provide some enhanced pain management options AND get the patient into the local pain management practice.

Idealistic?  Probably.  Would it require a lot of groundwork to get this set up?  Absolutely.   Regardless, I do think it’s an idea that meets an unmet need in virtually every community.  And as I understand it, community paramedicine projects are supposed to be meeting unmet mobile integrated healthcare needs.

Tell me how/why this wouldn’t work?

Filed Under: EMS, EMS 2.0

It’s not always THAT call

Posted on August 18, 2014 Written by

Last night, I had a challenging call.  The specifics don’t matter all that much, but suffice it to say that a rodeo cowboy had an isolated extremity injury where he wasn’t responding to much of the analgesia options I had for him.  The real issue arose when, on an isolated stretch of highway, the patient decided he wanted to get out of the ambulance, became both confused and combative, and saw me as the obstacle to getting out of the ambulance.  Ended up pulling the ambulance over, getting help from my partner, EMS management, and a lot of law enforcement. (By the way, I really do love my colleagues at the Blanco County Sheriff’s Office and the Johnson City Police Department!)

A challenging call?  Maybe.  Maybe not.  But it’s not always THAT call.  It’s funny what can be a trigger for each of us in emergency services.  One person’s bad call is another person’s idea of fun and excitement.  And it’s not necessarily that call in isolation.  It can be a run of “interesting” calls.  Most likely, it’s a combination of THAT call with whatever additional personal or professional stressors you’re dealing with.  And, at least in my case, it’s never a specific call.  It’s a call combined with other stressors.

Fortunately, one thing I have in my favor is an excellent support network of family, EMS colleagues, and coworkers.   A little bit of venting and discussing what’s on my mind, combined with some food and a lot of sleep helped to put things in a much better perspective.

I don’t have much advice to offer about any one specific call or stressor in your life, but I can tell you that the more you keep your problems to yourself, the less help and support you’ll feel you have.  Stop the self-fulfilling prophecy and talk to someone.  Emotions become self-doubts and cascade into things much worse without an outlet.  Family provides unconditional acceptance.  EMS colleagues and coworkers provide the understanding of the challenges.  You have to have a support network that includes both.

And heck, if you’ve got no one else to talk to, I’ll listen.

Filed Under: EMS

Being a Sheepdog

Posted on August 11, 2014 Written by

A good friend of mine who’s a non-practicing paramedic and currently serves as a law enforcement officer out in the Texas Hill Country had a good post on Facebook about the current divide in this country and how it’s also manifesting itself in the divide between law enforcement and the public they serve.

I’d say the gap exists, not just between law enforcement and the community, but between public servants (police, fire, military, and EMS) and the community.  There’s a lot of reasons, I’m sure, but allow me to throw some thoughts out there.

For better or worse, and certainly without ill intentions, we have created a lot of those barriers.  We’ve hidden behind artificially created barriers between “us” and the public we serve.  We cite “homeland security,” “officer safety,” and “HIPAA” as reasons why we no longer engage with the public or create barriers to such engagement.

Several years ago, while on vacation in an unnamed large city known for legalized gambling, buffets, and neon signs, I stopped by their central fire station to get some photos and maybe meet some firefighters and/or medics.   The garage bay doors were closed and there wasn’t even a doorbell to ring.  I walked around to another door and there was a phone to pick up.  When I explained that I was a visiting medic from Texas, I was promptly told that their station wasn’t open to visitors or the public.

Combine that with some communities encrypting all public safety communications (granted, I have ZERO problem with encrypting sensitive channels like SWAT, narcotics, surveillance, etc.) and eliminating ride-alongs, and you’ve created an environment where a communications barrier exists — and where rumor and conspiracy theories can flourish.

Yes, those of us who are public servants are the sheepdogs who protect the sheep.  If anything, that means even MORE of an obligation to be amongst the sheep.

My advice: be approachable.  Let’s be the ones who remind the public that we’re here for them.  Otherwise, as we’ve seen this week near St. Louis, those who reflexively dislike us will have ample opportunity to spread their message.  For better or worse, we live in a constitutional republic and we are servants of the public.  It behooves us to gain and maintain the public’s trust.  One can practice “officer safety,” “scene safety,” or “situational awareness” without coming across as a member of an occupying army.  Take off the wrap-around shades, interact with the public, and show a kid (or even, gasp, an adult) your vehicle.  It’ll keep you safer in the long run.

Ok, rant over, y’all.

Filed Under: EMS, Politics, Rants

Hypocrisy much?

Posted on July 24, 2014 Written by

I read a lot about EMS in a lot of different forums.  And invariably, almost anytime something goes wrong, there’s a debate about “this wouldn’t have happened in my system.”  That’s usually followed by the inevitable debate about what model of EMS delivery to have, whether it’s fire-based, third service, private, hospital, or what have you.

I’ve heard a lot of medics accuse the fire service of wanting to take over EMS.  Heck, I’d even say there’s some validity to those arguments. When modern construction techniques and fire safety codes have dramatically reduced the number of structure fires, you have to have something for the guys and gals at the station house to do.   I’ll also concede that many large city fire departments pay lip service to the EMS mission and have a culture that doesn’t condemn lackluster care.

But ya know what? When you, as a third service, private, or hospital-based medic automatically say that the fire department either can’t or shouldn’t do EMS, aren’t you just the flip-side of the fire chief who says that only the fire service can do EMS?  Like them, you’re dismissing, often arrogantly, the prospect that just because someone wears a certain uniform, that they’re incapable of providing clinically appropriate, compassionated medicine?

What I’ve found in EMS, at least in the USA, is that every community has different needs, different demographics, different politics, and different resources.  The EMS model that Las Vegas uses might not work in rural Kansas.  And probably neither would work in inner city Houston.  That’s the beauty of EMS.  We’re always adapting.

So, as a personal request from your favorite blogger (Oh, wait, I’m not Kelly Grayson!), I’ll ask the fire medics to chill with the “ambulance driver” comments and attitude.  But for those of us whose ambulances aren’t red, we need to drop the “hose jockey” comments and saying that our patient isn’t on fire.

And by chance, if you’re in a system where you have first responders from another agency, take the time to work with them, help train them, and eventually, they might just rise to your expectations.  Canceling them, clearing them from the scene early, or talking down to them only means that they will be utterly and completely incapable of helping when you really, really need that second set of hands on a bad scene.

Just my $0.02 after reading some pretty heated stuff the last couple of days.  At the risk of sounding overly simplistic, we’re all supposed to be on the same team.  Let’s start acting like it.

 

Filed Under: EMS, Rants

Rookie to medicine and blogging

Posted on July 19, 2014 Written by

How many of us remember our early mistakes, whether in emergency medicine, blogging, or anything else?  I sure do and I wince at a lot of them.  Regardless, our mistakes hopefully help us grow.

A good friend of mine who’s also a paramedic in the Lone Star State has recently taken up the blogging habit.  His blog is new and it’s got growing pains like we all do, but what’s awesome is watching his growth as a medic.  He’s still got some growing to do, but what I’ve seen of him is well worth reading and following.  He’s someone I’d trust to care for my family.

Visit his blog at Rookie Blues.  It’s worth the time to watch someone who’s growing into being a good blogger, a good medic, and a better person.

Filed Under: EMS

A social media plea

Posted on July 12, 2014 Written by

We’ve all been there.   Whether it’s the 4 AM tones for a self-entitled diva who feels that her prescription refill needs a ride to the big city hospital or a drug addict who claims allergies to aspirin, Tylenol, Toradol, and ibuprofen, we’ve all felt abused, mistreated, and neglected by the public we serve and our colleagues in medicine and public safety.

Venting among friends and colleagues is a perfectly normal, reasonable, objective way of letting some of that frustration and anger go.  Been there myself.  I vividly remember being at the end of a 36 hour shift and getting toned out for mutual aid one town south of me with less than 45 minutes to go.  That ended up being a 40+ hour shift with a patient, who on arriving at the large academic medical center said, “Maybe I don’t need to go to the hospital after all.”  I remember letting flow a non-stop stream of obscenities the entire way to the call and back from the call.  (By the way, sorry about that, Michelle and David!)

What I don’t do (at least I hope I don’t) and what most of the rest of us don’t do is to show this side of us in public.  It’s not professional and it doesn’t inspire confidence in the EMS system.

But here’s what we keep doing — we keep posting memes and pictures on social media about “EMS abuse,” “drug seekers,” and every other perceived person or complaint that we don’t deem worthy of our time as medical providers.  Amongst ourselves as EMS providers, that’s one thing.  But when you share it publicly on your “wall,” or worse yet, when a major EMS website shares these kind of messages, it sure as heck denigrates our profession and takes away from our message of being compassionate providers who are there as public servants.

I’m not saying not to complain, gripe, moan, or vent.  Let’s just keep it to ourselves.  Because when the public sees this underbelly of EMS, we can’t really complain when they call us “ambulance drivers,” can we?

 

Filed Under: EMS

An Open Letter to the EMS Media

Posted on July 2, 2014 Written by

Ambulance Chaser here.  Overall, I’m a huge fan of EMS media, both online and print, and making EMS information available online to our fellow professionals.  However, I’ve noticed a disturbing trend in several of the EMS websites and publication.  The articles related to law and EMS legal issues tend towards sensationalism, inducing panic and fear amongst providers, click-bait, or stirring up business for the attorney writing the article.  Articles on liability tend to report on isolated, extreme cases out of trial court verdicts or settlements, which do not create binding law anywhere.  And more than one article has ended with information about how to contact the attorney-author for more solutions to the problem they happen to be writing about.  And we know that HIPAA and privacy issues are routinely invoked as bogeymen waiting to trap unsuspecting EMS providers, when we all know that realistic common-sense measures address most compliance issues.  But that doesn’t drive up “clicks” on the website nor clients to the lawyers to purchase a tailor-made compliance handbook and checklist.

And let’s not even talk about the constantly invoked specter of losing your license, getting sued, or gasp, going to jail.  Yes, EMS provider liability exists.  (Honestly, in my opinion, I think more providers should be sued for some of their acts.)  But the liability for EMS providers and EMS systems is a creature of state law in the overwhelming majority of cases.  Continually citing an attorney who practices in one of the worst possible states for tort liability is at best, fear mongering, and at worst, disingenuous.  It’s as self-interested as for a CPAP vendor to write an article on how and when to use CPAP.  Heck, most of the publications put that kind of obvious infomercial in a “special supplement” to the magazine.

And heck, we’re ignoring several of the big issues in the legal arena that continually “bite” EMS — wage and hour claims, employment discrimination claims, tort liability for vehicle operations, and compliance with state administrative regulations.  But of course, it’s much “sexier” to write about some case where some medic in West Cornfield got sued because of a bad outcome for the patient.  Posting an article like that, of course, brings out the legal experts who populate Facebook and social media.  And that drives up the clicks on the website.

For EMS to progress, we are going to have to develop our own core of “experts” in fields related to EMS, including law, politics, and policy.  At the risk of sounding exceedingly self-interested, I believe I fit into that role.  I am one of the few attorneys who’s actively practicing both law and paramedicine.  I bring a focus on addressing and managing risk to legal issues, including those in EMS.  Additionally, with much of my career being in state government, I have a real understanding of the political, regulatory, and advocacy processes that many in EMS do not possess. (If you’ve read my blog in the past, you know my thoughts on what’s right and wrong on our efforts at advocacy and politics.)

I’m not asking for a column or a position (although I’d certainly be open to it).  What I would respectfully request as an reader as well as a practicing EMS provider is that we demand the same excellence in media addressing EMS legal issues as we would clinical issues.

Sorry for what seems like a more self-interested post than usual, but, to a large extent, what the EMS media is publishing as legal education is just not what most providers need.

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