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.

On passion

Posted on January 15, 2014 Written by

I was discussing the role of passion in EMS with a friend of mine.  She reminded me that there are plenty of people with a passion for EMS who don’t have the aptitude for EMS.  That got me to thinking.

Maybe there’s a distinction to be made.  The people who are the long-term successes in EMS have passions for the right things about EMS.  You know, things like the actual practice of medicine, the life-long learning, and the compassion.

Because if all you are passionate about the ability to drive with lights and sirens, sleep on duty (not that the “safety nap” is a bad thing, mind you), and get two days off after working twenty-four hours, you’re quite likely to have one of two things happen to you.  Number one, burnout when you realize that real-life emergency medicine in the field has no resemblance to the infamous EMS t-shirts claiming that you’re a “Trauma Junkie doing everything the doctor does, only at 80 miles an hour.”  Number two, disappointment when you’re one of the people posting on a Facebook group that “you love EMS and want to be a paramedic, but you’ve already failed National Registry three times, so it must be the fault of your instructors.”

Be passionate about the medicine, not the perks.

Filed Under: EMS, EMS Education

Praise in public…

Posted on January 9, 2014 Written by

Scold in private.   That’s the old saying.  And usually, I try to follow that advice.  Well, usually.  Less than a month ago, I posted some deserved criticisms of an EMS response and the organization’s followup.

Early this morning, my mother had another emergency that required a response from our local EMS system (Austin/Travis County EMS).  This response was the polar vortex (to use the current Weather Channel cliche) of an opposite to the previous response.   From the initial 911 call-taking to the handoff at the emergency room, Austin/Travis County EMS proved that it can still provide compassionate and proficient patient care.

The Austin Fire Department first responders and the Austin/Travis County EMS paramedic crew worked as a true team to deliver compassionate and clinically competent medicine to my mother.  Sure, they recognized the cardiac arrhythmia and treated it properly.  But equally importantly, they nailed all the little things just right.   Before they brought her outside on a stair chair, they made sure to provide a blanket.   And when we got to the hospital, the other paramedic even mentioned that he avoided a certain notorious street so as to avoid the potholes and bumps on the way.

I apologize if I embarrass anyone, but the following people deserve praise in public — the entire crew of Austin Fire Department Engine 21, including Firefighter/Paramedic Dave Williams, the crew of Austin/Travis County EMS Medic 7 — Paramedics Jacinto Andry and Randy Vickery, and Austin/Travis County EMS District Commander Temple Thomas.  You’ve more than redeemed the system to my family.  You provided comfort and care.  That’s what EMS is all about and I cannot thank each of you enough.  It’s my sincere hope that these words from a fellow paramedic and (hopefully) a friend can begin to express my gratitude to each of you.  Each of you represent what this local EMS system is supposed to be about.  Your care, your compassion, and your treatment reflect highly upon both yourselves and your colleagues.

Thank you.

Filed Under: EMS

Top Ten EMS Marketing Gimmicks

Posted on January 4, 2014 Written by

From our home office in Ladonia, Texas, we bring you the Top 10 EMS marketing gimmicks.  If you’ve ever been to the exhibit hall of an EMS conference  or read the back of any EMS magazine, you’ve probably seen some of these gimmicks in play when it comes to marketing a new product designed to make our lives as medics easier.  For your reading pleasure, I’ve compiled them here.

 

10. “Complies with AHA standards.”

9. Vague claims that your new EMS product is now “the standard of care.”

8. “When seconds count.”

7. Claim your product is eligible for “homeland security grants.”

6. Work the word “rescue” into the product name – even if it’s a pen.

5. The Star of Life.  Everyplace.

4.  Add webbing to it.

3. Color it black or subdued gray.

2. Call it “tactical” – even if it’s just a disposable bed sheet.  Adds a 15% markup.  Minimum.

1. Flaming skulls.  Never forget the flaming skulls.

Operators are standing by.

Filed Under: EMS, Humor

EMS provincialism

Posted on January 3, 2014 Written by

Every EMS system thinks their model is the ideal model.  And the truth is that it may be — for their locale.

However, the truth is not every model of EMS delivery can transfer to everywhere else.

In other words, Reno is different from Seattle which is vastly different from New Orleans.  Anyone selling a one system fits all model is either a consultant, a charlatan, a fool, or any combination of those three.

Filed Under: EMS, EMS 2.0

Making good paramedics

Posted on January 3, 2014 Written by

If you listen to the folks from Boston, Seattle, and, to a lesser extent, Austin, you’ll hear that the secret to good paramedics is to have a small core of paramedics backed up by a larger group of EMTs.  The theory is that the paramedics will be at the top of their game as they are reserved for those patients who truly require advanced life support care. In these systems, one promotes into the paramedic position, usually after working several years as an EMT, regardless of the certification level they were hired at. (In other words, in these jurisdictions, you can be a state-certified paramedic, but working only as an EMT.)

Minions, allow me to call BS on this.  First, how does working as an EMT for a few years make you a better paramedic?  Second, what’s an advanced life support call?  I’d be almost willing to bet you that a fractured extremity isn’t considered an ALS call.  Want to bet that the patient with a fracture would like a paramedic on scene.  If that patient wants pain medications, there’s going to have to be a paramedic there.  And yes, while I definitely buy the argument that too many paramedics lead to skills dilution, the skills that a paramedic truly needs, in other words assessment and critical thinking, come in on every call. As for intubation, chest decompression, and other “sexy” skills, they can be compensated for through skills labs and hospital rotations.

If we’re really worried about wanting to produce good, experienced medics, I’ll throw out two suggestions.   First, have a good hiring process and a good salary and working environment.  That will go a long way towards ensuring that your applicant pool consists of good, experienced paramedics.  As for the inexperienced providers who have the potential to become good paramedics, hire them and put them through an extended internship where they work as a third crew member with experienced providers.  Give them the opportunity to learn and practice while still having the safety net of experienced providers with them.  I had an opportunity to ride as a volunteer medic for several years with Harris County ESD-1 (later Harris County Emergency Corps) as a third crew member, which gave me a ton of experience and confidence dealing with some very sick patients.  That time at HCESD-1 and HCEC made me the paramedic I am today.  (I can supply the names of partners to blame if you’d like…)

I realize that my experience as a volunteer third medic isn’t the same, but I definitely believe that offering an extended paramedic internship would be an improvement over requiring an arbitrary amount of time spent as a paramedic functioning in an EMT capacity.  That model is nothing but a system wide application of the shopworn cliche of “BLS before ALS.”  It’s time that emergency medical services approaches career development through an internship paradigm rather than through a “pay your dues” mentality.

Happy Friday, y’all!

 

 

Filed Under: EMS, EMS 2.0, EMS Education

When EMS will begin to improve….

Posted on December 27, 2013 Written by

A lot of my friends in EMS complain about fire-based EMS.  I’ve been among them, although I think the problem with many of the large urban fire-based EMS systems is that they’re large.  Once a service becomes too big, it’s hard to manage effectively and even harder to prevent a “lowest common denominator” practice of medicine.

The one thing I’ll give the fire service is that, even when they bitch about being on the ambulance, they indoctrinate a love of the job. And that’s not something you always see in the non-fire-based EMS world. Where is the EMS version of Alan Brunacini teaching customer service or our version of Rick Lasky teaching “Pride and Ownership?” EMS will begin to improve when people who love being paramedics are running EMS systems.

And if you don’t love being a paramedic (or EMT), there are plenty of ways to deal with the burnout, whether it’s a change of employer, more education, or finding an alternative practice setting. (You know, there are non-ambulance settings where you can be an EMT or paramedic.)  But until we fill EMS with people who WANT to be in EMS and who understand that clinical excellence and customer service/problem solving skills are both critical, we’re still going to be the ambulance drivers.

Filed Under: EMS, EMS 2.0

Christmas Eve thought

Posted on December 24, 2013 Written by

For those of you who know me away from this blog, you know I’m Jewish — heavy on the “ish.”  In fact, I’m probably the number one Jewish connoisseur of bacon and baby back ribs.  Heck, I’m too apathetic to even be an atheist.

But this time of year does lead you to some almost religious thoughts.   I’m not a Christian, but I think there’s some wisdom from the New Testament.   Come to think of it, just about every religion has a core message that boils down to “be nice.”

So, here’s my message to my EMS colleagues, whether or not you’re working on the holiday:

“I was sick and you visited me.”  Matthew 25:36.

If that doesn’t sum up what being a medic is all about, I don’t know what is.  Merry Christmas, y’all.  (Yep, not my holiday.  Doesn’t mean I can’t tell you to enjoy it anyways.)

Filed Under: EMS

11-20-2013

Posted on December 22, 2013 Written by

November 20, 2013.  6:06 PM.   That’s a time that will live in my memory for a long time and that I will probably never be able to forget.  You see, at that moment, my mom became an EMS patient and I simultaneously lost faith in my local EMS system.

 

It’s hard being a medical provider when your family is a patient.   It’s even harder watching an EMS system you’ve always respected do everything it can to disappoint you.

 

I’ve always considered myself fortunate to live in Austin, Texas.  Besides the great BBQ, we’ve always been proud of our EMS system.  Until the early 2000’s, the local EMS department patch proudly proclaimed “System of the Year 1984.”  And recently, Austin/Travis County EMS received accreditation from CAMTS, the Commission on Accreditation of Medical Transportation Systems.  Surely, this system can’t disappoint, right?   This isn’t one of those big city fire-based systems or one of those  “eeeeevil” for-profit low bid contractors.  This system is one of the best funded in the country.   The medics are exceptionally well paid.  In fact, both of the medics who came to “take care” of my mom made over $80,000 last year.

 

This is the system that I grew up in as an EMT-B, first responding with one of the county fire departments and riding as a third on their ambulances.   This is the system that has a new hire academy that’s several months long and then an extensive field training process that lasts several months as well.   Not to mention a full-time “Professional Practices and Standards Division” and two full-time physician medical directors and several part-time associate medical directors.  If you believe their PR machine, this is the best EMS system in Texas, if not the United States.  In other words: Bad. Things. Do. Not. Happen. Here. Period.

 

So, here’s what happened.  Just before 6:00 PM that evening, my mom had an episode where she couldn’t remember the last two hours of her life.  This episode ended up lasting a total of about 20-25 minutes.  During that time, I called 911 for EMS help.  (And we know that when her paramedic son insists on an ambulance, she’s sick.)   The firefighter/EMTs who showed up from the Austin Fire Department did a great job of getting a set of baseline vitals, ruling out the possibility of a stroke, and reassuring everyone.  Then, the responding EMS crew showed up.  Two paramedics, each with over ten years experience in the local EMS system.  You know – one of the elite EMS systems in the country.

 

Well, the treating medic comes up to my mom, who’s laying on the couch.  He sets his $25,000 LifePak 12 cardiac monitor down in front of the couch.  What does he do with it?  He uses it as a stool to sit on.  No.  I am NOT making this sh-t up.  He asks her a few questions and then says, “You’re not having a stroke and your symptoms are clearing up. If you want to go to the hospital, I guess we can take you.”  Me, being the concerned son, I said that she definitely wanted to go to the hospital.  Here’s the next shocker.  The same medic says, “You’ve got a steep driveway and we can’t get the stretcher up the driveway.  You think you can walk down to the ambulance if we help?”   Did I mention that my mom has aortic stenosis?  You know, that’s a heart condition.  Me?  I was too shocked to say anything.  So, the medics walk a cardiac patient to the ambulance – in the cold rain.   They were “nice” enough to allow me to ride in the back with mom.   During the transport, the medic kept his nose buried in his laptop and the only thing he “did” for mom was to put her on an automatic blood pressure cuff.  Because, yeah, that’s what you do for a cardiac patient.  I almost forgot to mention that they knew I’m a medic.  One of them asked the firefighters, “Is this guy riding with you?”  The firefighters said I was the patient’s son and a paramedic.  So, they knew they were being watched by someone who knows what the drill is.  Think what they’re doing when they aren’t being watched.

 

So, Mom got admitted to the hospital for a couple days worth of diagnostics where they finally determined she had inadequate cerebral perfusion due to her aortic stenosis.  She was scheduled for a heart catheterization and valve replacement.  She ended up having a single vessel bypass and an aortic valve replacement on December 12th and is recovering remarkably well.   So, at this point, we’ve more than determined her EMS care way missed the mark.

 

On the way home from the hospital on the night of the 20th, I began to have more and more concerns about the EMS care she received.  One thing that Austin/Travis County EMS is also proud of is a 24-hour customer service line that rings to the on-duty field supervisors.  You’re supposed to receive a return phone call within 30 minutes.  So, when I hadn’t received a phone call by the next morning, I shot off an email to the EMS Director and the EMS Medical Director.   Part of becoming an attorney means losing any and all fear in upsetting the apple cart.  Besides, it’s my mom.  And somewhere during EMT and paramedic training, I learned we’re supposed to treat every patient like we’d want our mom treated.

 

So, eventually, they had a field supervisor (district commander in the Austin/Travis County EMS lexicon) call me.  He acted concerned and mouthed the customer service phrases just like someone would if you called in a complaint to the cable company or the phone company.  He also promised that a “duty medical officer” would call me to discuss the clinical aspects of her care.  As promised, the duty medical officer called me back.  He too mouthed the customer service catch phrases and told me that I would never find out what happened as a result of his investigation because of certain statutory provisions mandating confidentiality of clinical reviews of EMS providers.

 

After a couple of weeks, I began to wonder what happened to my initial complaint.  I spoke to the district commander again who told me that “they” made the decision that the concerns I had were clinical, not operational, and that the complaint had been closed.  As this didn’t make any sense to me, I talked to one of my many contacts at EMS.  That person told me there wasn’t even any record of the complaint being taken.  When I heard this, I turned lawyer.  Full-on lawyer.  I sent what only be described as an attorney demand letter via email to the EMS Director, the EMS Medical Director, the deputy EMS Director, as well as the city manager, assistant city manager for public safety, the city attorney, and the city auditor.  I explained my very real concerns as well as my mom’s fear to call EMS again.  I demanded a meeting and that it was my very intention to file a formal complaint.  I got my meeting.  I met with the EMS Director, deputy EMS Director, the deputy EMS Medical Director, and the assistant chiefs for operations and professional practices.  During that meeting, my email was turned into a formal civil service complaint against both the responding medics as well as the district commander who “deep-sixed” my complaint.  I also got the opportunity to discuss the call in-depth with the deputy EMS Medical Director who seemed concerned and said that the events warranted investigation.  I left at least semi-reassured.

 

After my mom’s successful surgery and as her recovery continued to progress well, I turned my attention back to the care she received.  With a HIPAA release in hand, I got a copy of her EMS report.  Not only was the report’s narrative full of misspellings, grammatical errors, and incorrect capitalizations, it was remarkably incomplete in describing what the EMS crew observed and heard from the patient – and her family.  As an adjunct to my legal and EMS careers, I’ve presented several times on EMS documentation.  Based on my expert opinion (Yeah, I’m arrogant that way.), I can, without a doubt, say that this is some of the worst documentation I’ve had the misfortune of running across.  Surely the deputy EMS Medical Director would want to know about this.  After all, he told me to call with any concerns I had.

 

So, I called him.  And yes, he had seen it.  And yes, he agreed it “wasn’t good.”  However, he also told me that the clinical review was complete.  He also went on to tell me that the clinical review process wasn’t about discipline, but about educating the crew.  Ok, I can almost go along with that.  Nevertheless, at some point, one has to wonder at what point education and remediation cease to work and discipline may be warranted.

 

So, the doctor told me that he “talked to the crew and this won’t happen again.”  Wow.  I feel better.  Especially when the same day, the local news reports that Austin/Travis County EMS suspended a paramedic for two 12-hour shifts for making inappropriate posts on Facebook.  However a combination of clinical errors that could well have had a negative patient outcome gets a “talking to.”  Hell, they might have even been sent to bed without cookies.  Maybe at their next shift at a slow “vacation station,” they’ll have to give up their Xbox time.   I should also mention that the treating paramedic has a disciplinary record including two negligent collisions and failing to follow a directive from a district commander.   So, there’s a documented history of laziness and an unwillingness to abide by department policies.

 

Fortunately, I did file a complaint with the state on the responding medics.  Here’s hoping that the state recognizes this substandard care for what I believe to violate multiple state administrative rules relating to EMS.  What amazes me is the number of local medics who weren’t surprised by the treatment from this crew.  Ignorant, lazy, and arrogant were among the nicer words I heard to describe these two paramedics.  Yet, our supposedly elite local EMS system allows these two to continue on providing slipshod, lazy, complacent, minimal standards of prehospital care while paying each of them over $80,000 a year. For $80,000 a year, I’m more than happy to put a patient on a cardiac monitor and schlep a stretcher, stair-chair, backboard, or scoop stretcher to the patient’s side.  Wait.  I do that most weekends.  For free.  Yep.  I’m a volunteer paramedic.  I provide compassionate, clinically competent medical care almost every weekend.  So, there’s another take-away from this incident:  paycheck status does not correlate to professionalism.

 

As I finish this blog entry, I am seriously doubtful that much more will be done to any of the personnel who I’ve mentioned here.  So, I’ll close it here with a thank you.   Thank you to the two responding paramedics, the district commander in question, and the deputy EMS Medical Director.  Y’all have succeeded in ruining my opinion of a supposedly elite EMS system.  You’ve shattered the years of PR about a “great” EMS system – and you’ve convinced a 66-year-old mom with heart disease that there’s no reason to call an ambulance.   The worst part is, based on the lack of care that she received, I have a hard time arguing otherwise. Well done, y’all.

Filed Under: EMS, Rants

Controversy for the day.

Posted on December 19, 2013 Written by

Here’s another crazy idea for EMS.  I’ve heard it from several people in the past and I think I could get behind it.  What do y’all think?

Let’s separate the emergency response side of EMS from the pure interfacility transport realm.  Emergency calls and emergent responses to healthcare facilities (e.g. nursing homes and physician’s offices calling for a patient to be taken to the emergency department of a hospital) would continue to receive ambulances staffed by emergency medical technicians and paramedics.   Non-emergent interfacility transfers would receive a response from a transfer system.  Transfer systems would be staffed by nurses’ aides and vocational nurses who have received extra training and an endorsement in patient movement, patient transport, and vehicle operations.  As for the true “critical care” patients, the ones on multiple medications and/or ventilatory support, the minimum standard should be a true critical care paramedic.  In other words, a paramedic with a true critical care background (and yes, I realize there are a ton of competing critical care certifications) and possibly backed up by nursing and/or respiratory care practitioners.

A while back, I blogged about owning what you excel at.   EMS excels at providing emergent/acute care interventions on an unscheduled basis.  In other words, 911 calls and emergency responses.  Let’s focus on that.

Filed Under: EMS, EMS 2.0, Uncategorized

On liability…..

Posted on December 16, 2013 Written by

Another observation from the Ambulance Chaser on EMS liability.  Yes, it’s true that there’s a ton of immunity from civil liability for EMS providers, especially those employed by a government agency.

Here are some other truisms that didn’t make the cut.

1) Immunity from liability doesn’t equal immunity from suit.  In other words, there’s absolutely nothing to prevent you from being sued for any reason or no reason at all.  And guess who’s going to pay for your legal fees?  Yep.  You guessed it.  In most cases, you’ll be paying for an attorney.   Even if your employer provides legal counsel, be certain of who they represent.  Your legal interests and your employer’s legal interests may not necessarily be one in the same.

2) Lawsuit aside, you can always face administrative liability from your state or local EMS regulatory body.  What does that mean?  Quite simply, even if you can’t be found civilly liable for your foul-up, it’s quite easy to even inadvertently violate your area’s EMS laws and regulations, especially since most of them have a generic rule saying “don’t be a Whatshisname.”  Granted, you probably won’t be subject to a huge financial hit like you would from a lawsuit.  However, you’ll still probably want an attorney to defend your certification/licensure.  And yep, that governmental body can sanction, restrict, or revoke your certification.

3) Finally, just like any other employer, someone can always complain to management about you.   So, yep, your bosses may have the supervisors, HR department, or the clinical folks investigate you.  And management definitely considers employees to be their greatest asset — until said employee becomes a liability.

So, here’s some advice that I borrowed (with permission) from Mr. Too Old To Work, Too Young To Retire, who’s now happily retired from a large third-service New England EMS system.

1) Answer the radio when the dispatcher calls you. Or the page, or the phone, depending on how you are dispatched.

2) Go to the call as quickly as safely possible.

3) Be courteous to the patient and family.

4) Take them to the hospital.

5) Keep them warm, as in make sure they are comfortable and have a blanket.

 

And the other advice from your friendly neighborhood Ambulance Chaser — GET LIABILITY INSURANCE.  It’s not just about the ability to pay a lawsuit judgment (which we know is unlikely), it’s about the insurance company having to provide you with a lawyer if you’re sued.  And many liability policies cover legal fees relating to an administrative complaint or hearing as well.   To me, your livelihood is worth it.

Filed Under: EMS, EMS Legal
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