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.

Starting at the bottom

Posted on May 8, 2014 Written by

Lately, on Facebook, there’s been some debate.  (Or what passes for debate on Facebook — AKA, monkeys flinging poo.) The Facebook EMS forums have been all abuzz about the idea that some EMS systems don’t hire you in as a paramedic and that you have to work as an EMT for a couple of years before promoting into a paramedic position, regardless of your state certification level.

Let me say that I think this is a flawed model.  Do I have the science behind ALS skills retention and the number of ALS interventions out there?   Nope, I don’t.  I won’t even deny that there’s only a few patients who really need the whiz-bang ALS stuff such as intubation, but that’s not all there is to being a paramedic.  But, I think the way to learn being a paramedic is by being a paramedic. And a good paramedic assessment is something you can perform on every patient.  Symptom relief, whether pain management or nausea management is one of those ALS skills as well.  Good BLS skills are definitely the foundation of competent paramedic care, but at some point, the “everyone is an EMT for X number of years” model is going to turn away experienced providers. The BLS skills model also works really well when you have short transport times to definitive care as is the case in Boston and most parts of Austin. (Heck, the Houston Fire Department even recognizes this and tells their EMT crews to initiate emergency transport for any trauma patient they encounter in inner Houston.)

As for me, I was very fortunate to have the opportunity to “grow” as a medic in a very high volume, high acuity EMS system with exceptionally broad and aggressive protocols developed and implemented by a full time medical director.  New full-time medics went through a FTO process before being released as a second crew member.  To be the lead (AKA in-charge) paramedic took an additional FTO process.   As for volunteers, you rode as a third crew member while retaining the ability to practice virtually any skill available to your certification level and, after a period of time, could challenge the FTO process.  For me, that process worked.  It worked quite well.  While I’m no longer with that service, I appreciate my experience and routinely refer back to it with almost every call I run.

There’s no secret about these places (most notably Boston and Austin) that hire paramedics into the role of a basic.  They tell you in advance that’s what it’s going to be.  There’s full disclosure.  If you don’t like that process, you don’t have to apply.  And while I don’t have the numbers, my supposition is that a lot of experienced providers aren’t interested in such a process.  Sadly, many of the younger, inexperienced medics who’d benefit from an extended skills development process and FTO program because of a lack of maturity, both as a person and a provider, also lack the maturity to recognize that they need such processes. Civil service produces a lot of good benefits for medics — namely a well-defined process for HR issues.  What it also produces is a relatively static culture that promotes from within, and without careful attention from management, promotes an insular groupthink.

In conclusion, I’d say that the model that Austin and Boston use is the model they’ve decided on.  If you don’t like it, don’t apply.  But to those services, when you have an extended FTO and promotional process, you have to recognize that you’re unlikely to attract experienced medics.  It becomes a self-fulfilling prophecy.  You can’t attract experienced medics to such a system, so the system becomes even more rigid to adapt for inexperienced medics requiring more initial training and mentoring.

Yep, when the only tool you have is a hammer, everything starts looking like a nail.

Filed Under: EMS, EMS 2.0, EMS Education

Activism masquerading as medicine

Posted on May 7, 2014 Written by

As most of you have no doubt figured out by now, I tend towards the right of center, fluctuating between conservatism on economics, crime, and foreign policy and more on the libertarian side of social issues.  (Want an abortion, marry your same-sex partner, or smoke pot?  I don’t care.  Just don’t ask me to subsidize it.)

I don’t care what your politics are, personally.  I have friends who make Pat Robertson seem like an atheist and friends who make Barack Obama look like the founding member of the Tea Party.

What I do care about is when you use a position of authority to claim to be an unbiased authority — or when you use your position as my physician to promote a political or social agenda — regardless of the cause.

As of late, I’ve seen physicians advocate for gun control, against extraordinary rendition of terrorism suspects, for air pollution controls (in the name of prevention of children’s asthma, no less!) and against fast food.

What I’m unclear about is where the practice of medicine ends and where the political advocacy begins.  From the looks of it, many physicians are too.  Years ago, public health meant epidemiology and disease prevention.  Now, the modern liberal nanny state has morphed public health into a form of political activism.   I’ve got no problem with advocating for your agenda, just don’t say that your position is a matter of medicine.  Because if doctors can make law by virtue of their medical education, it’s a short jump before lawyers are able to make medical policy by virtue of their legal education. And we all know how well that works….

Filed Under: Politics

We may not be doctors, but we’re not bouncers either

Posted on May 4, 2014 Written by

I’m either fortunate or cursed enough to live in Austin, Texas, which bills itself as the Live Music Capital of the World.  As part of that, we’re also home to South By Southwest, a giant musical festival that allows Austin to be the temporary capital of hipsters and music executives during that time.  (And here’s my obligatory kudos for the super work by the medics of Austin/Travis County EMS, the firefighter first responders of the Austin Fire Department, and the Austin Police Department during the mass casualty incident…)

One thing that SXSW is full of is guest lists, especially for private parties.  And these guest lists get enforced by bouncers and velvet ropes.  In other words, if you’re not cool enough to be on the list, you don’t get in.

EMS doesn’t have private parties.  (Ok, if we do, I’m not telling.)  But so many medics want to function as bouncers for the ER.  “Well, we can take you to the hospital if you really want to.” “Yes, but it’s 10 o’clock and the ER will be busy.”

Or if we do let you past the velvet rope into the ambulance to take you to the ER, some of us treat people as the “not cool” crowd.  “I stick everybody with at least an 18 gauge.” “I only give pain medicines if I think they need them.” Or my personal least favorite, “I’ll BLS this call.  We’re only X minutes from the hospital.”

The one recurring theme that I find with “bad” medics is a continued unwillingness to do the job — namely, to take people to the hospital and (hopefully) improve their condition by the time they’ve gotten there.  Nowhere in any EMS job description does it add the caveat: “But only if you think the patient is worth your time.” Don’t be a bouncer.  Be a clinician.

Filed Under: EMS

A case with relevance to EMS?

Posted on May 3, 2014 Written by

Here’s a law firm’s press release worth reading.   Why?  Because it actually provides an appellate law citation.  In this case, it’s from the New York Court of Appeals, which makes the decision binding case law in New York.

The case determined that, in the state of New York, emergency department physicians have no legal duty to detain an intoxicated patient and prevent them from leaving the emergency department.

I’d note that this case only applies to New York and the facts of the case only apply to the legal duties and obligations relating to an emergency department physician.  But this is a case that applies regularly to EMS, assuming we deal with intoxicated patients.   The laws applying to EMS are likely different than the physician patient relationship and will definitely differ in other states.  It’s a case that’s eventually going to happen to EMS and this appellate case potentially might give us some clues as to how courts, at least in New York, might view the issue.

But the legalities of dealing with an intoxicated person are much more relevant to EMS legal issues than constant crowing about the supposed illegality of EMS providers making a diagnosis, whether EMS stickers on your car create a duty to act, or any of the other legal nonsense that EMS legal discussions regularly devolve into.

 

Filed Under: EMS, EMS Legal, Law

Two contradictions in healthcare.

Posted on May 3, 2014 Written by

1) The nursing lobby continues to push for advanced practice nurses to have more privileges, but continues to oppose EMS providers being able to practice community paramedicine or function as EMS providers in the emergency room.  Why?  Because that’s supposedly unsafe for the patient to be seen and treated by someone with less education than a nurse.   Funny.  That’s the same argument that physicians use to say that advanced practice nurses still need limitations on their scope of practice and for physician oversight.

2) You know the people in EMS who claim that EMS providers are legally prohibited from providing a diagnosis because only a physician can?   Funny, aren’t they providing legal advice without the benefit of passing the bar exam?  And by the way, their legal opinion also happens to be wrong.

Critical thinking.  It’s contagious.  Here’s hoping you catch it.

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

Is EMS about to keep itself irrelevant?

Posted on May 1, 2014 Written by

With much ballyhoo and publicity, we’ve heard a ton about increasing educational requirements for EMS.  The National Registry now requires a paramedic candidate to have graduated from an accredited paramedic program.   What does accreditation mean?  Speaking cynically, it means that an education program has gone through a process where it has created a big ol’ (Yep, “big ol'” is a Texas colloquialism, so deal with it…) policies and procedures process that may or may not have anything to do with academics and/or successfully creating baby paramedics.

And at least some of the EMS world is clamoring for a degree requirement for paramedics.  They’re convinced that a degree for paramedicine will enhance both pay and professionalism.  They point to nursing as an example where this has happened. Perhaps.  Maybe.  Respiratory therapy now has degree programs and, if I remember correctly, its pay hasn’t skyrocketed like nursing.  Correct me if I’m wrong.

What concerns me about the EMS education trend is this.  We are continuing to look at an EMS degree as a technical thing.  More hours in the hospital.  More hours in the classroom learning what paramedics already know how to do.

What EMS hasn’t done is grow a future generation of EMS leaders and thinkers.  We need paramedics who know public health, public policy, management, the political and regulatory processes, and dare I say it, the legal realm. EMS is a business, whether it’s publicly run or a private enterprise.  Johnny and Roy may know how to intubate, but if Johnny and Roy can’t make a budget, deal with HR, and deal with Capitol Hill, Johnny and Roy are going to remain the bastard stepchildren of healthcare.

If we’re going to have a debate about a paramedicine degree, let’s be sure that we know what a paramedicine degree should contain.  And let’s start growing a cadre and a core of EMS subject matter experts in all of the fields that touch EMS — not just experts in EMS.

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

On Politics

Posted on May 1, 2014 Written by

I rarely get political here for two reasons.  First, my political beliefs are all over the place.  I’m overall somewhere between conservative and libertarian on most issues.  When it comes to foreign policy, I often make Dick Cheney look like George McGovern.  But I also think that Elizabeth Warren and Bernie Sanders may be right about the Wall Street crowd being bad for our economy long-term.   Second, most of y’all are here to read my EMS brilliance, or what passes for it.   However, I ask your indulgence as I go off on a rant against a trend in American politics that I don’t like.

In short, if your ideas or agenda can’t win in the political arena, that should tell you something.  You’re not winning.  Either accept the defeat graciously or you repackage and resell your ideas to the public.

However, instead, we find both sides, but primarily the modern Left, resorting to enacting public policy through litigation and/or the “public health” arena.

Texas and several other states have been the subject of litigation by anti-death penalty activists seeking to expose the suppliers of execution drugs.  While they couch their arguments in terms of the public’s right to know, the reality is that they are using the courts and the legal process to try and enact a political agenda that hasn’t won in the legislative process.  As an attorney, I try to view the courts as the means to resolve a dispute between two parties rather than as a way to enact social changes.  If you want to enact social changes, run for office on your platform and see how it stands with the voters.

And let’s look at “public health.”  Years ago, I imagined the word of public health as focusing on epidemiology and disease prevention.  Now, the way to control people’s lifestyle has become through the “public health” process.  Want to ban trans fats?  Simple.  Call it a public health crisis.  Want to ban big Cokes?  Call it a public health crisis.  (And yes, the Texan in me calls every soft drink a “Coke.”  Welcome to Texas, the only state you’ll be asked what kind of Coke you want and it’s ok to answer with, “I’ll have a Sprite, thanks.”)  Want to ban guns?  Call it a public health crisis.  To me, the real public health crisis is how many parents ignore science in favor of Jenny McCarthy and refuse to vaccinate their children.

What we really have here is a public policy crisis where those people who want to enact unpopular agendas resort to an alternative way to enact them.  And on that note, I return you to your regularly scheduled internet agenda of cat memes.  Thanks for listening, y’all.

Filed Under: Law, Politics

Be the change. Infiltrate.

Posted on April 24, 2014 Written by

So many people have complained about the lowest common denominator (or “low information voter” AKA LIV) tendencies in EMS and EMS management (both clinically and operationally) ad nauseum. What we haven’t done is begun to fix it. The path is deceptively simple. Infiltrate. Infiltrate. Infiltrate. There are tons of committees, focus groups, etc. out there. Imagine if each of these committees had a strong advocate for higher EMS standards on them advocating for change or at least showing the way.

Currently, I’m up at NREMT helping review EMT exam questions. Watching a medic’s eyes pop out at reading a sepsis protocol that involves more than fluid resuscitation has been worth the trip alone.  I don’t blame him.  I blame his regional system for maintaining a lowest common denominator EMS system.  I blame the fire departments and private services that want a lowest common denominator system for the express purposes of lower wages and/or ease of training.

Get involved. Infiltrate. Be the Fifth Column that corrodes the lowest common denominator mentalities from the inside. If nothing else, it adds to your personal contact list.  And just maybe if we have the advocates for high quality EMS networking with each other, high quality EMS becomes the denominator.

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

Endangered Species

Posted on April 15, 2014 Written by

So, I recently read an article online in Fire Apparatus Magazine bemoaning the state of EMS. Because, as we all know, the most current information on emergency medicine comes from a magazine that shows pictures of big red shiny trucks.

When you go through the article (I’m not going to link it because I don’t want to give this guy any more legitimacy), he raises the standard argument that fire chiefs and large EMS system managers always use as their stalking horse in their arguments to keep EMS educational standards low — or even lower them. Yep, that’s right. The mythical rural EMS volunteer who will disappear if we change the science and/or add one more bit of knowledge to their already overflowing brain.

I feel more than qualified to address this issue. I’ve spent the majority of my EMS career as a volunteer at both the EMT and paramedic levels with both fire-based systems and third service models. I’ve worked urban, suburban, and rural. The majority of my experience has been in combination departments where paid and volunteer medics work side-by-side. And to the premise of this article, I say, “BULL.” Well, I said more, but this is a family-friendly blog.

I’m more than tired of using the overworked rural volunteer provider as a straw man. First, regardless of whether you draw a paycheck or not, an EMT or paramedic certification is the same. In many states, you can’t say the same for a paid versus unpaid firefighter. Second, in my experience, volunteers are some of the most motivated people out there when it comes to seeking continuing education and opportunities to advance their medicine. In the rural service where I currently volunteer, we have an active continuing education program consisting of monthly online classes as well as a full panoply of “card courses” covering resuscitation, cardiac care, medicine, trauma, pediatrics, and tactical medicine. Our medics, at all levels, routinely exceed state mandated training requirements. I’d further note that several of our paramedics are volunteers who work in outside professions and maintain licensure in those professions as well. Furthermore, come to any of the big EMS conferences. There, you’ll notice a disproportionate number of volunteer providers, especially compared to those employed in large EMS systems.

In short, Chief Haddon of the North Fork, Idaho Fire Department is wrong. Volunteer EMS providers can, will, and do exceed educational requirements and expectations. Give them a chance and you’ll find out. And if you don’t believe me, I’m extending a personal invitation to come down to Texas. I’d be happy to introduce you to some volunteers who actively seek to improve themselves professionally for the benefit of their patient. Heck, I’ll even treat to BBQ.

I’m not expecting a visit, though. It’s a lot easier to use the myth of the overworked, overwhelmed volunteer EMS provider who will go away if we add one more class. Sadly, this “don’t need to know it mentality” usually only benefits the “mongo mentality” of “you call, we haul” that seems to hold back EMS. The worst part is that the same departments and administrators who bemoan increased EMS education can be seen at all of the structural fire conferences. Maybe its time to have more volunteer EMS systems and less volunteer fire systems?

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

Heresy in a paragraph (or less)

Posted on April 14, 2014 Written by

A few years ago, the formerly ALS skill pushed to the masses was the Epi-Pen.  Now, it’s Narcan.  What’s different?  Simple.  Narcan is going to be needed less in the field but will probably be used more. What would work is teaching people how to properly ventilate with a BVM.  It fixes the real problem (depressed respiration) and has more uses than just an opiate overdose.  But why should we teach BVM skills?  After all, it’s barely taught properly to EMS types.

And let the heresy accusations begin.  At least I didn’t bring up backboards.  Yet.

Filed Under: EMS, Rants
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