Another Volunteer Crisis

As sure as the day is long, we can count on the EMS news sites to do a post on the volunteer crisis in fire and EMS organizations. And EMS1 did its part yesterday.

And of course, y’all know I have to comment.  So, let’s do a rehash and repeat.

Folks, it’s real simple. Too many organizations make it hard to volunteer, whether its applying or what’s required to remain a member. I’ve lost count of the number of volunteer organizations that don’t have their membership application online. Likewise, I’ve lost count of the number of “all hazards” departments that will allow volunteers to remain exclusively firefighters but won’t allow for EMS only volunteers, even when well over half of most departments’ call volumes are for medical calls. I’ve also lost count of the number of departments that are combination departments that only offer their “mandatory” training during the week when we “normal” people with an office job are already pulled in multiple directions. (Hint: There are infinite platforms online to make these classes available on demand or as webcasts.)

I’ve always held the position that standards should never be lowered. All that most volunteers (or potential volunteers) ask for is a bit of flexibility in how you reach those standards. Something as simple as allowing a volunteer more time or the ability to work with different field training officers could be a huge asset in getting a volunteer cleared to independent duty, especially as an advanced life support provider.

If you don’t believe that there’s a pool of volunteers out there, do this.  Look at how many people out there hold a fire and/or EMS certification and are currently unaffiliated with any service, whether paid or volunteer. If the National Volunteer Fire Council, NAEMT, or any of the other fire and EMS groups are truly serious about volunteers, I’d recommend a survey targeted at those people to find out why they’re not currently volunteering.  If you wanted to go above and beyond, survey those people who are active volunteers with departments not near their home.  Find out why they’re not affiliated with a closer department. Dollars to doughnuts, the answers will the same — there will be some artificially created barrier preventing them from volunteering nearby.

I’ll also note that the value of a volunteer group, especially in a combination department, isn’t immediately obvious until you have a disaster or other incident that’s stretched your department thin and/or exhausted mutual aid resources.  That guy who’s just a volunteer EMT can now free up the paid firefighter/EMT staff from medical calls.  That lady who’s qualified to drive and operate a tanker/tender means that apparatus is now in service and the paid crew isn’t cross-staffing it.

Unless of course, your goal is solely to show that you “can’t find volunteers” and really need that sales or property tax to hire paid staff. If that’s your real agenda, then, by all means, keep on doing what most departments seem to be doing. Sadly, in my neck of the woods, this strategy has been effective as a jobs program for paid firefighters and EMTs.

More on the Four Year EMS Degree

So, I’m thinking more about the push for an EMS degree. In theory, I think it’s a great idea. But here’s a couple of observations.
 
The “other countries have it” argument. Those other countries also have a national healthcare system where EMS is integrated into healthcare. We don’t have that in the United States. Additionally, some of these other countries don’t have a tradition of mid-level practitioners that the United States does like advanced practice nurses and physician assistants, so in some of these cases, paramedic providers are stepping into roles that might be filled by other healthcare professionals here.
 
As a corollary to that, much of our EMS is provided by the fire service and by large private EMS companies. The fire service does EMS because it “has to” in order to maintain some justification for its existence. It has no interest in EMS save for staffing and budget. They’re not going to be advocates for EMS. As for the privates, they want low wages and lower educational standards, since they’ve got a long history of churning through employees and needing a steady inflow of new people.
 
Volunteers. Yeah, truthfully, it’s going to be hard to require a four year degree to volunteer on the ambulance. And unfortunately, there are parts of the USA where the local authorities have chosen not to fund an EMS system or there’s not sufficient people to do it. As the old adage goes, you get the EMS system you pay for.
Clinical outcomes. Everyone talks about evidence based medicine, including me, until they don’t like what it says. Is there any evidence that a more educated paramedic provider has better clinical outcomes. Australia and Canada both have college-educated providers and that’s become the norm there. Yet, these paramedics often have a more limited scope of practice than many locations in the United States.  Is there any evidence to indicate that American paramedics with a lower educational standard and (often) a broader scope of practice have worse clinical outcomes than their more educated foreign colleagues? As a further question, would a four year degree expand the current scope of practice for American paramedics?  As a liberal arts graduate myself, I believe the real value of a four year degree comes from the critical thinking and communications skills that a core liberal arts curriculum develops, but the majority of EMS degree advocates seem to believe that only a four year EMS specific degree is going to “save” EMS.

Actual logistics. Let’s assume that we do decide to put in a degree requirement for paramedics. Let’s further assume that it’s going to be a four year degree. How many degree programs exist? Are there sufficient faculty with an “appropriate” terminal degree in the field to satisfy the higher education accreditation authorities?  And on that note, what is an appropriate terminal degree for EMS?  Would we now end up inadvertently or intentionally creating a doctorate in EMS education?  Would current EMS educators be ineligible to continue what they’re already doing? The demand for nurses and nursing education has already created a shortage of nursing educators.  What would EMS education do to meet that demand on day one?

What would happen with an actual EMS degree requirement?  The skeptic and cynic in me says that most places wouldn’t have degree-educated paramedics.  Instead, the “powers that be” will do one of two things.  They will continue the current paramedic education and call it something else.  Or they will water that down even further and create another “paramedic light” certification. See also: Rhode Island’s EMT-Cardiac, New York’s Advanced EMT-Critical Care, NREMT Intermediate-99 (thankfully being phased out), Virginia’s EMT-Intermediate, or Iowa’s “paramedic” based on the NREMT I-99 standard (the actual “full” paramedic in Iowa was called a “paramedic specialist). And I will make you a bet that the majority of large EMS operations in this country will immediately default to providing service at this “paramedic light” level.

 

If we want degree educated paramedics and believe that’s for the best, we’re going to need to answer these questions.  And we’re also going to need find the funding for this. That probably means getting the primary payer of EMS services, the Federal government, to change Medicare/Medicaid so that EMS systems are paid for treatment and services rendered rather than just transport mileage.  But to do that means that we’re going to have to be more involved in the political process rather than the occasional appearance on a designated “lobby your politician” day where you wear a uniform that looks something like a third world dictator. The truth be told, increased EMS education and increased EMS reimbursement are like the chicken and the egg.  I don’t know which comes first.

 

I’d also point out something said by a former EMS director of mine.  He said he’s paying paramedics (and EMTs) what he can afford to pay them, not what he wants to pay them.  Again, until reimbursement changes, there’s no magic source of increased paramedic compensation, even with higher education.

Before you think I oppose an EMS degree, let me say that I don’t.  I believe that a four year degree is appropriate for a medical professional. I also don’t know that all of the advocates of an EMS degree have fully thought out the impact of such a requirement, even if gradually phased in.

I believe that our current America EMS system may be like Churchill’s definition of democracy. Churchill said that “Indeed it has been said that democracy is the worst form of Government except for all those other forms that have been tried from time to time.…”  I believe that we may find this to be equally true for American EMS if we suddenly change our educational paradigm without considering the consequences.

These concerns and this rant was brought to you by a mostly proud graduate of a certificate granting paramedic program who also had a bachelor’s degree in liberal arts followed by a graduate and a professional degree. Higher education taught me to think. Paramedic education taught me to do. And coming into a paramedic program with a college degree taught me to think and consider what I do as a paramedic.

On The EMS Degree

So, because of a prominent fire chief’s article against EMS degrees, all of the usual EMS advocates are coming out for a gradual phase-in of a degree requirement. And it stands to reason that the fire service wants a low entry standard for EMS.  Most fire departments, especially the larger urban ones, see EMS solely to justify their existence.  Smaller fire departments often see taking on the EMS mission as a way to get increased funding, most of which will go toward the big red trucks and not the ambulance.  In many fire departments, the ambulance is actually called the “penalty box.”

In theory, I’m in favor of a degree requirement to be in EMS, especially at the paramedic level. More education can and should produce better paramedics. But with some experience in both consuming and regulating higher education, I know that giving power to higher education can have unexpected consequences.

So, since this train seems to be gathering some steam, let me throw out my conditional support.  I hope the advocates for EMS education and those accrediting college based EMS programs will listen before we hear about these issues arising once a degree requirement is truly and fully implemented.

  1. Grandfather current providers. I’m told that’s already in the works, but requiring everyone to back and upgrade to an EMS-specific degree would likely overwhelm each of these college based programs.  And for those who already have a bachelor’s or higher in a field outside of EMS, it would be unnecessarily repetitive.
  2. As a condition of accreditation, college-based EMS programs should be required to explicitly state how they plan to meet the needs of EMS students, especially those who are currently in the workforce. Such a commitment should address hours that the courses are offered, locations of the courses, transfer-ability of hours for non-EMS specific courses, and availability of clinical sites.  If you ask why I have a paramedic certificate instead of a paramedic degree, I’ll give you a simple answer.  The community college based program serving my area only offered the paramedic program on a full-time basis during daytime hours only.  With an outside career and already having three degrees, attending a certificate-only program was a no-brainer.
  3. Distance education is a must.  It stands to reason that those against an EMS degree will use the “poor volunteers” as a stalking horse to protect those who stand the most to benefit from poorly educated EMS providers — namely the fire service and the larger private EMS systems. Ensuring that EMS degree programs have distance learning AND nearby clinical rotation sites will ensure that rural and volunteer systems have their needs addressed — and eliminate one more argument against an EMS degree.
  4. In an ideal world, I’d like to see some sort of promise or commitment of an alternate entry degree program for those who already have a bachelor’s degree or higher. Such a program should be tailored to get people the scientific background they need for prehospital medicine (primarily anatomy and physiology) and the coursework necessary to function as a paramedic.
  5. Finally, the accrediting bodies need to ensure that these commitments and promises from higher education are kept ongoing. It will be entirely too easy to start backpedaling once the initial accreditation occurs.

I sincerely hope that those who advocate for an EMS degree take this in the spirit in which it’s meant — a reasonable way to ensure that we actually accomplish the goal of creating better educated paramedics and not solely in guaranteeing higher education a continued revenue stream. If we don’t plan now to address the needs of EMS providers and foresee unintended consequences, we are guaranteed to create even more of a shortage of providers (although some might argue that’s not an entirely bad thing) and creating a group of providers with significant student loan debt to go into a field not known for the highest wages.

We have one chance to get this right.  Let’s make sure that happens.

Where To Fix EMS

We all know the problems with EMS.  Mostly they revolve around low pay, low standards, and unreliable sources of funding.  Easily fixed, right?  Well, maybe.

But there’s an ongoing problem in EMS. Most EMS systems operate under the belief that good clinical skills (or even worse, good clinical outcomes) are the primary determinants of who gets promoted.  Being a good clinician involves more than clinical skills.  And being a good clinician doesn’t mean you’re going to be a good educator or a good manager. Being a good clinician doesn’t correlate with much besides being a good clinician.

What does EMS lack?  And more importantly, what do most so-called EMS “Leaders” lack?  They lack the “soft skills” besides how to read an EKG, intubate, or start an IV. They may have a professional network, but they don’t know how to use it.  They rarely understand politics at any level — from the local government who decides how to fund and provide EMS to the state officials who regulate EMS to the federal officials who determine how Medicare and Medicaid reimburse EMS. They don’t understand the value of public relations.  They rarely understand budget and finance.

Ok, so you get the picture. So what is EMS doing about it?  Well, we’re doing the same thing as always.  We’re promoting folks on their clinical skills at best and most often based on who they know or how much management likes them. We’ve created a system where most EMS employers don’t have much of a career track.  And we continue to tell our best and brightest to move into another medical field, whether nursing, medicine, or physician assistant.

What should we be doing?  Simple.  Let’s actually grow our own EMS leaders and not just the usual gang of experts/idiots who speak at every conference simply because they’re loudly exclaiming they’re leaders.  Let’s encourage the best and brightest to remain in EMS and further their education.  They already know how to be EMTs or paramedics.  What they don’t know is what to do next.  Let’s get people degrees in adult education to become clinical educators.  Let’s get people degrees in business management or public administration so they can effectively manage and lead an EMS organization.  Let’s get people educated in finance to figure out how to keep the crews paid and fuel in the trucks. And maybe even get a few of us into law school and admitted to the Bar.  After all, we’re in healthcare, one of the most heavily regulated fields in the marketplace.  Having someone who knows how to navigate the legal, regulatory, and political landscape might just help advance EMS a bit more than just another guy who says “Narcan” at the right time. And since EMS is a business, maybe having someone with some marketing or public relations skills might help the public (and the politicians) understand that not all EMS is created equally and that, like anything else, you do indeed get the EMS system you choose to pay for.

Or…. we can keep doing what we’ve been doing.  The current results speak for themselves.

The Social Media Medic

Social media is a wonderful thing.  It truly is.  For me, as both a paramedic and an attorney, it has been a godsend.  I’ve made a lot of friends that I’d have never known otherwise.  And, especially for medicine, it’s exposed me to a lot of new topics that enable me to give the best possible care to my patients.  The discussions in both law and medicine (and the combination of the two at times) make me think and grow in both professions.

However, there’s an old adage that applies. Caveat Emptor.  That’s Latin for “Let the buyer beware.” Like I said, social media is often a good thing, especially in EMS. But while it gives everyone a voice, its downside is that it gives everyone a voice, including those that might not be the best to listen to.

There’s a category of people I call the “Social Media Medic.” They’re the first to jump into a discussion with absolute certainty and moral clarity as to how you should be practicing medicine and what kind of person you should be. They protect their brand by saying all the right things because, often, their brand is the only thing they have and that’s how you get to make it on the EMS conference circuit. The “Social Media Medic” is often full of buzzwords and hashtags about EMS and medicine.  They’re often posting studies and blogs that promote them and/or their agenda. Sometimes, some of these people don’t even understand the study that they’re sharing. On social media, these people say all the right things.  They have the right hashtags.  They have the message down.  They might even be right.  But we rarely have a way to confirm that the loudest voice is the most correct voice.  Heck, on more than one occasion, I’ve found that some of the loudest voices who are the most insistent that they are right about medicine are those who are virtually unemployable in their field, often because their social media personality is a reflection of their actual personality of being an insufferably arrogant buffoon.  In other words, what the Greeks used to call sophmoric, literally a “wise fool.”

I’ll admit that I’ve been active on social media.  Some might even say I’m too active. They might be right. The truth is that I’m far from God’s gift to EMS.  I make mistakes daily and I don’t get enough time to do as much medicine as I’d like to be truly proficient. After all, as Clint Eastwood said, “A man’s got to know his limitations.” Hence, I rarely post about actual clinical issues in EMS.  It’s just not something I feel that I have the expertise or status to comment on with any authority. Now, legal issues, politics, volunteering, or professionalism are areas I feel qualified to comment on, so I do such.

In short, the loudest voice isn’t always the voice we need to be listening to.  And that especially rings true in EMS social media.

Why Doesn’t EMS Grow Up?

Social media is always full of EMS providers committing social media assisted career suicide (SMACS).  The latest was a perceived HIPAA violation where a medic was perceived to make fun of a cardiac arrest in a chicken coop, along with the associated chicken “byproducts.”  EMS Week always brings out the memes where the least bright and engaged of us in EMS demand to be thanked for our service, whether with free gifts or attention. We’re heroes, dangit. And EMS social media is always full of posts complaining about “misuse” and “abuse” of EMS and the emergency department of hospitals.

Of course, EMS and emergency department “misuse” and “abuse” are very subjective things. The general public doesn’t have the same definition of emergency that the average EMS provider has. Try to do the right thing and call your doctor after hours and you get a recording saying “If you’re having an emergency, hang up and call 911.” The problem is that no one defines emergency. Try to find after hours or unscheduled care for any sudden issue and you find that same or next day appointments are few and far between.  Urgent care hours often aren’t significantly better than many large clinics and that’s assuming that they even accept your insurance.  And if you do get in to see your doctor at their office, you can expect multiple follow-up visits for labs, imaging, and specialists for all but the most minor complaints.  Each of these are a separate absence from work and a separate insurance copay.  Is it any wonder that people go to a hospital emergency department where no appointment is needed and there’s virtually instant access to labs, imaging, and specialists.  As I like to say, the problem isn’t EMS or emergency department abuse, it’s that primary care has turned us into their after hours call coverage.

But that’s not the real point here.  The point here is that EMS seems to continue to remain in a teenager phase of not wanting to listen to the “adults” in the room who talk about educational standards and professionalism.  We continue to want to be “heroes” rather than caregivers and we demand attention and increased salaries while not doing anything to show why we deserve to be treated as a respected healthcare profession.  Why?

It’s simple.  The average career lifespan of an EMS provider, according to my quick Google search, is five years.  That’s right.  Five years.  It takes more than five years to be good at almost any career.  Like almost all of us, as a new EMT, then a new paramedic, I was full of all of the wrong answers.  I was full of dogma, misinformation, and the tendency to be way too eager about EMS. Fortunately, I was able to volunteer in some really first-rate EMS systems where I learned about medicine.  Also, the Internet and social media exposed me to some really smart people who actually cared about EMS and the medicine behind it.

However, the reality is this.  Many of the best and brightest in EMS leave for other careers in healthcare. And who can blame them? The opportunities in EMS pale in comparison to nursing, medicine, or as a PA, NP, or CRNA. With EMS’s short career half-life combined with our abysmal EMS education (Here, let me read the PowerPoints that the textbook publisher provides and I’ll throw in a war story on occasion.), we’ve created a revolving door of new providers who believe the dogma and misinformation.  They believe they’re going to be heroes and they’re disappointed when they’re providing geriatric primary care as opposed to “exciting and cool” trauma calls where they might “save a life.” (Spoiler alert:  Most of us in EMS don’t get the experience of being able to point to a specific life they’ve saved.  But if you do this right, you’ll get a lot of people to the right definitive medical care they needed to begin with.) And with our low barriers to entry, there’s little incentive to stick it out in EMS and make EMS great again. And while this revolving door continues, you continue to see EMS fail to progress and you see the same tired memes and complaints where we mock patients and our careers.  And when most are called to account for this behavior, they give the same tired excuses of how “you don’t know what it’s really like on the streets.”  Mind you, some of the worst offenders on EMS social media are virtually unemployable in EMS and don’t even work in an emergency setting.

To me, the heroes of EMS are the ones who’ve stuck it out; kept trying to improve EMS, even if it’s just their own EMS employer; and tried to teach good medicine to those coming in behind them.  If you actually took the time to take care of a sick person who’s septic and weak as opposed to bitching and moaning, you’re exactly who we need to stay in EMS.

What does the patient/client want?

I’m trying to put some complex and jumbled thoughts into words here, so bear with me. As some of you may know, I’ve dealt a ton with health issues for various family members over the years, especially over the last few months. One thing that I’ve seemed to notice is that too many people in healthcare think they’re helping when they’re substituting their own wishes and priorities for that of the patient and their loved ones. Further, many professionals in both medicine and law forget that the patient/client and their families have a life outside of and in addition to the matter currently being addressed. The outside world rarely pauses and often refuses to pause so that a patient/client or their family can reschedule the outside world at a moment’s notice all because someone feels that their little niche or agenda has to be addressed right this minute.

As a result, the patient and their family feel that the providers of all kinds, whether physician, nurse, therapist, or case manager, are dictating to them rather than caring for them. It can easily make the patient and family feel as if they have no control over matters relating to their care. Example: “You have to be here for a very meeting. Today.” Reality: Here’s the same discharge plan that we’ve been discussing for several weeks. 
 
People often feel an absolute loss of control of their care and their wishes. And when people feel they’ve lost control of their own affairs and that their wishes aren’t being heard, they’ll find another way to ensure they’re heard, whether in court or in filing a complaint with a regulatory agency. The nature of our healthcare and legal systems being what it is, the courtroom or administrative complaint is the only way that some clients/patients and their families feel that they will be heard.  (Free legal advice: it takes a lot less time and money to be nice up front and explain things early than it does to answer a lawsuit or an administrative complaint.)
 
Part of being a professional is in recognizing that the patient/client still maintains autonomy – the right to make their own decisions. Your job is, within the confines of the law and ethics, to help that patient meet their stated needs and goals. Being a professional means giving a patient/client the services and all of the information they need to make a good decision, then abiding by that decision and putting the patient/client first.  Heck, even as a lawyer, clients go against advice all of the time. Look how many criminal defendants insist on testifying in their own defense.  Look how many DWI suspects agree to take field sobriety tests and take the breathalyzer, even though they’re basically giving the evidence to convict themselves.  As I like to remind professionals of all sorts, people have the right to make bad decisions.  Fundamentally though, as a professional, we exist to provide services to our patients/clients in accordance with their wishes. 
 
This should ring true whether it’s medicine or law. And it’s a good prescription for limiting your involvement with lawyers to represent you. As another EMS colleague of mine says, “We can suggest, but forcing patients to do what they don’t want buys lawyers nice cars.”

“Dr. Dunning, I presume?” said Mr. Kruger.

An ongoing topic of discussion on EMS social media is the Dunning-Kruger Effect.  Wikipedia defines the Dunning-Kruger Effect as “a cognitive bias wherein people of low ability have illusory superiority, mistakenly assessing their cognitive ability as greater than it is.”  Over the past few days, I’ve seen some great examples of EMS’s collective Dunning-Kruger Effect.  I also call these moments “not knowing what you don’t know” or “doubling down on dumb.”

The greatest exhibit that I can present to illustrate EMS’s exhibition of the Dunning-Kruger Effect comes from a self-promotion post by a critical care transport educator.  This educator, while promoting a post from JEMS about a Texas EMS system’s decision to adapt their protocols to prevent ventilator-induced injuries, breathlessly exclaims “ICU care begins in the STREETS! i expect my medics to be BETTER than EM and ICU attendings. ALWAYS. Period.” (Note: capitalization error was taken directly from the posting.) In the spirit of self-promotion that afflicts so many EMS “celebrity educators,” the post goes on to promote his recent conference appearances where he discussed using ultrasound to identify lung injuries and adjust ventilator settings.

Here’s the thing.  I don’t know how good or relevant his presentation is. And we all have to make a buck. And if you don’t promote yourself, no one else will.  But there’s probably not a single paramedic out there who’s better than an attending emergency medicine or critical care physician/intensivist.  Having said that and having my own experiences to guide my opinions, I will say that there are many paramedics who can assess a patient and rapidly treat a critically ill patient better than a physician without emergency medicine or critical care education.  Heck, that’s the  primary purpose of critical care/retrieval/flight paramedicine. When a patient is critically ill in a remote setting or an outlying hospital without specialist resources, that’s why you have critical care transport capabilities.

And yes, a critical care medic is probably better than an EM/ICU attending at certain technical skills.  Notice I said skills.  Most physicians don’t deal with vent settings.  Why?  Because in an ICU setting, there are others to help with such things. The physician has their eye on the big picture.  General Patton might not have been the tank driver than an individual sergeant was.  He didn’t have to be.  He did have to know exactly how to rout the enemy on the battlefield and accomplish large objectives.  Similarly, a HVAC technician probably knows more about fixing a faulty air conditioner than does a mechanical engineer. But I can almost guarantee you that the mechanical engineer knows more about how a HVAC system works and fits into a larger picture than a technician does. Likewise, I have a good friend who’s a state trooper.  I can assure you that he’s better than me, a lawyer, at knowing the intricacies of DWI law.  But he’s probably going to have a harder time putting all of the law together to get a complete picture.  Technicians, like many of us in EMS, excel at particular technical skills, hence why they’re technicians.  Professionals excel at the big picture, synthesizing multiple sources of information, acting on said information, and leading a team to solve that problem, almost like a conductor leading a symphony orchestra. (Heck, in the emergency room, look at how a resuscitation is run.  The leader, usually a physician, is rarely performing skills, but rather leading others in what needs to happen.)

Yep.  EMS often illustrates the Dunning-Kruger Effect with our belief in our own expertise.  But I can’t completely blame us.  Over the past few days, I’ve also seen ham-handed attempts by EMS educational programs to engage in education on EMS social media that illustrate President George W. Bush’s infamous question, “Is our children learning?” One community college based EMS education program shared a viral news video of a police officer being administered Narcan for an “exposure.”  Unfortunately, the initial posting by the educational program was posted without context and showed a breathing police officer being administered Narcan for a possible exposure to a stimulant, most likely methamphetamine. As even the lay public is learning, administration of Narcan is indicated for respiratory depression secondary to an overdose of an opiate/narcotic.  In other words, a conscious, breathing patient doesn’t need Narcan.  And an EMS educational program should definitely know better.

But that may not be the worst.  Late last week, a nationally known bachelor’s degree program in paramedicine shared a guest blog post from one of their students. The article was about the controversy of allowing paramedics to intubate.  Well and good.  The topic is definitely worthy of further discussion, especially considering the limited access that many EMS education programs have to clinical sites for live intubation practice. Yet, the article soon disappeared from that college’s social media.  Namely, many EMS providers pointed out multiple misspellings in the post along with dated studies cited (the most recent was over ten years old) and the lack of mention of high-fidelity simulation or more recent science supporting safe intubations through delayed sequence intubation by EMS providers.  Presumably, this blog post was reviewed and approved by the college’s faculty prior to going live. Sadly, when this kind of writing is presented by an educational institution, the writing serves only to reinforce negative perceptions of EMS by the rest of the healthcare community and remind them that the “ambulance drivers” aren’t yet at the same level.

The truth is that EMS does a good job at its core mission.  We excel at providing urgent and emergency care in the out of hospital setting and using a public safety skill set to do such. Our knowledge of the medical field is an inch wide (unscheduled out of hospital care) and a mile deep in that field.  Let’s own that field for ourselves and quit trying to prove how smart we are.  Inevitably, when we stray too far afield and when we keep calling attention to ourselves, we too often illustrate the Dunning-Kruger Effect.  These moments don’t advance EMS.  On the contrary, they remind us why everyone except for EMS providers get to make decisions about what happens to and for EMS.

 

How To Create a Paid Fire/EMS Department

As of late, I’ve posted a fair amount about the local politics involved with the various tax-funded emergency services districts in my part of Texas basically ending volunteer participation. Truth be told, I definitely think there’s some shenanigans from paid staff and their union locals. But folks, if we’re going to talk about the end of volunteer participation, we need to take a long hard look at the volunteer culture.

As I often teach through sarcasm, I present the following recommendations for ways to ensure that your volunteer department becomes a combination department and eventually a completely paid department.

  1. Run the department as your own private social club.  By gosh, this is a place for the connected locals to hang out, use as a private lounge, and maybe go travel on someone else’s dime.
  2. Training?  Why do it?  And if you do feel you have to do it, focus on cool, fun stuff instead of the basics of being able to operate at a fire, rescue, or medical call.
  3. Membership? Who needs that?  If people want to join us, they’ll find us. And if they do figure out how to join the department, ensure that the process is all about who you know rather than what you’ll bring to the department. And if you do a membership drive, make it a joke.  Either try to recruit “heroes” (as opposed to members who want to help others) or do the same tired routine that you do every so often and then claim “nothing’s working.”
  4. Speaking of what you bring to the department, always make sure to turn down free help. If the person can’t make the arbitrary number of meetings or responses, or lives “too far,” don’t show any flexibility.  If you’re a combination fire and EMS organization, be sure to turn down someone only interested in one discipline. It’s not like having an extra medic frees up a firefighter or vice versa.
  5. Accountability and transparency is for the birds.  You’re heroes!  There’s no need to justify your budget or be accountable to those politicians at the county or the city who “don’t understand what we do.”
  6. Speaking of budgets, let’s be sure to spend like drunken sailors on shore leave. Buy those big-ticket, rarely used capital expenditures regularly, then run around scavenging for IV needles and working radios.
  7. Responses?  We’re volunteers.  We don’t have to go to a call if we don’t want to.  And we sure don’t go to “old so-and-so’s” house or the local nursing home.  It’s not like they really need help. And especially if you have paid staff working with the volunteers, there’s no need to go to all calls, only the fun ones.  And if you show up on the fun calls and don’t get to do “fun” stuff, by all means, complain loudly.
  8. Uniforms?  They need to fall into one of two extremes.  Either no uniforms and look like “People of Wal-Mart” or uniforms that make you look like an Italian Field Marshal.  No need for things like photo ID cards, t-shirts, polo shirts, and jackets.  It’s either the Redneck Yacht Club or the full parade dress.
  9. Be sure to remind new members that they don’t know how “we do things around here.”  Be especially unwelcoming to experienced people who have significant prior experience.  It’s not like they bring anything to the table.
  10. Don’t create strong relationships with the other members of the public safety team.  No need to play well with the surrounding fire or EMS agencies, much less law enforcement.  It’s not like you’ll ever need any of these guys again.
  11. And if you have a state organization for volunteer fire and EMS, don’t join it.  And if you do end up joining said organization, ensure that your organization is quiet at the state capitol.  We don’t want to antagonize the paid guys or advocate for volunteers.

So, if you follow my  program, what will you get?  Simple.  Eventually, the taxing entity and taxpayers will tire of your antics. They will point to your lack of training, transparency, fiscal responsibility, and shrinking membership roster.  First, they’ll bring on a small duty crew during the day to “supplement” the volunteer staffing.  Eventually, that supplement supplants the volunteers.  And somewhere during this process, your department becomes absorbed by the taxing entity.  Congratulations! Your non-profit volunteer group has now become a fully paid local government department.  But of course, the fun only begins.  All of the time and effort that you could’ve spent on having a functional volunteer or combination department can now be spent on lengthy political and legal battles over who gets the property from your department.

This story repeats itself over and over again, yet we don’t seem to learn.  The average volunteer emergency services provider is often their own worst enemy and the biggest reason why departments go “professional.”

And so it goes.

Cleared To Practice, AKA: The License To Kill

I booted up the computer fully intending to write a long screed, aka rant, on the issues currently facing Austin/Travis County EMS, its medical direction, and their relationship with the multiple county first responder agencies and their ability to provide EMT-Intermediate, oops Advanced EMT (showing my age) and paramedic level care.  I’ll still comment on that, but in terms of ATCEMS’s model being an example of one of two extremes of the EMS field training or credentialing process.

This cartoon/meme has been making its way around EMS social media and has popped up on my Facebook feed more than once already today.

Having been in EMS for roughly 14 years now, I’ve seen a variety of methods of providing field training.  They run the gamut from “here’s the keys” to “you’re repeating your paramedic clinicals with us for the next six months.”  As with anything in EMS, we run between two extremes and rarely find the “Goldilocks” point of being just right.

In some EMS systems, the FTO and credentialing process exists in name only.  At one unnamed EMS service, my official FTO process consisted of one ride with a field training officer for twelve hours.  Since I’d been off the truck for a while before starting there, I asked for more time before I even got that.  I got a shift before that where I was officially riding as a third crew member, until the paramedic FTO didn’t show up. Combine that with a chest pain call and the EMS director showing up on scene and asking if I was comfortable with taking the patient 40 miles and my field training process existed primarily on paper.  Of course, when you’re at a rural service that’s already short on staff, much less advanced providers, a field training process seems like a luxury that you can’t afford.  In my opinion, that’s a risk management nightmare.  When a clinical (or operational) failure happens — and it will, the discovery process that a lawyer will engage in will expose these shortcomings and present them to a jury of twelve citizens who couldn’t figure out how to get out of jury duty.

Then, there’s the other extreme.  Let’s take a large, unnamed third service EMS system that’s had an extensive process for bringing on new paramedics.  For many years, that process consisted of several months of a new hire academy then a field training process of several more months.  In short, the process to become a paramedic in this system became a virtual repeat of paramedic clinicals. Then a different medical director came in and decided that there were “too many paramedics” and required new hires to function at a modified EMT level for one to two years before being eligible to “promote” to paramedic.  Let’s now throw in the dozen or so fire departments in the county that provide EMS first response. Ever since before I got into EMS, this EMS system was unwilling to credential first responders above the EMT level. That’s their prerogative. But don’t say you’ll allow it and then make a process that’s so obtuse and arbitrary that it’s a virtual impossibility to credential. The previous medical directors and the department’s clinical management created this mess and they’ve now given the fire departments the rationale to create their own EMS programs. In fact, said county (cough, Travis County, cough) just created its own medical direction to give the county fire departments the ability to run their own paramedic first response program.  And that doesn’t even include two of the fire departments that have created their own paramedic-level ambulance service.

There’s a saying in the law that those who seek equitable relief must come to the table with “clean hands.”  In this case, I have to say that neither party have clean hands.  The EMS system wanted to be the sole provider of advanced life support in the name of “patient safety” and other benevolent sounding reasons for turf protection.  The various county fire departments want paramedic first response and in some cases, transport, to justify their budget and existence and to satisfy the various firefighter union locals that want their members to be an “all hazards department.” In short, to quote Mel Brooks as the governor in Blazing Saddles, “Sheriff murdered! Innocent women and children blown to bits! We’ve got to protect our phony-baloney jobs, gentlemen.” Fire codes have dramatically reduced the number of fires out there.  In Texas, many of the fire districts are funded by property taxes. Also in Texas, there’s a healthy skepticism of government and taxes.  Without EMS call volume, many citizens would wonder what they’re paying a fire department for.  Personally, I’d have much less heartache about the county’s decision to provide its own medical direction for the fire departments if this outcry for separate medical direction had been occurring for years, rather than over the last couple of years that have also been associated with the virtual elimination of volunteer response in the county and the addition of a second tax district in some of these fire districts to “support EMS.” If I feel for anyone, it’s the current medical direction of the EMS system.  They’re passionate about good medicine and supporting the practice of good prehospital medicine.  They’re also in the unenviable position of fixing a system that believed its own public relations for too long and had frayed, if not outright violated the trust of its supposed “partner” first response agencies.

So, what is the happy medium for field training and bringing on new people?  I don’t have studies or statistics to support my general concept of what works.  What I know doesn’t work is handing someone the keys to the controlled substances and saying “Good luck.”  But I’d also question the value of a lengthy process that is a virtual repeat of paramedic clinicals.  In theory, the certification exam for initial certification should provide some assurances of entry level competence. (That in itself is an argument for another day.)  In my ideal world, I’d argue for a field training and credentialing process that is competence based, rather than based on calendar days, clock hours, or getting a certain magic number of certain patient populations.  And in some cases, we’re rarely going to see certain patients in the field.  That means access to a skills lab and/or simulations and scenarios. The process should focus heavily on the unique clinical aspects of that particular EMS system, whether in regards to airway management, medications, or other uncommonly encountered interventions. The process also needs to focus on the operational aspects of being a provider in that system. How many of us haven’t been taught which channels/talkgroups are on our radios?  That, along with resupply, fueling, and documentation requirements often get overlooked in the FTO process. As much as we need to ensure clinical competence, we also need to ensure that a new medic (at any certification level) in the system knows what’s supposed to happen to make good patient care happen.  And let’s not even discuss transport destination determination, which is regularly overlooked.  Getting the right patients to the right hospitals is a core function of EMS and neither initial EMS education nor the processes to bring a new provider into an organization usually address this.  As a result, we routinely end up taking critically ill patients to hospitals incapable of caring for them.

I’ve ranted for a while and I appreciate the indulgence.  The short version is that, like much of EMS, field training and bringing new providers on board a system is a collection of bad practices and extremes. We can do better.  Both our profession and our patients (aka: customers) deserve it.