COVID 19, Free Money, and Excuses

Posted on April 20, 2020 Written by
This is a bit far afield from my usual blogging about the world of EMS, but if you think big picture above and beyond considering what clinical skills an EMT or paramedic should have, maybe this is exactly about EMS.
A couple of things about COVID-19 and business and government. As most of y’all know, I’m a practicing attorney with over 16 years of experience in government law, so I think I have some qualifications to comment.
 
1) In regards to the availability of the various loans, contracts, and grants, especially to small businesses and individuals that all levels of government are providing, it’s no surprise to me that they’re not getting where they need to be. Government moves slowly, even when it’s trying to move fast. And when it does move fast, it often fails to consider how the program will work. (See the current Paycheck Protection Program loans and how they seem to really overlook certain businesses, especially the restaurant business.) There’s an art to doing business with or getting money from the government and it usually takes a level of sophistication to navigate it. Sometimes, it’s not merit that gets the money as much as it’s the person or company that knows how to fill in the paperwork best. Early in my career in state government, the state agency that I worked for regularly contracted for advertising services for a public relations campaign. The company that regularly got the contract had hired one of our agency’s former office managers.  One of said manager’s duties prior to leaving state employment was reviewing contracts and preparing the bid and contract documents.  In other words, that company knew exactly which forms to fill out and what answers were expected on the document. And how does this relate to EMS?  Simple. Let’s think about some of the EMS grants out there.  We know that certain EMS agencies nationwide have the expertise to apply for grant funding.  These same agencies get every grant they apply for  Meanwhile, there are small EMS services struggling to keep supplies on the ambulance that have neither the time nor the savvy to navigate the grant process while at the same time, the right large systems get a WMD trailer, a HazMat truck, and a tactical medicine supply that would keep the Green Berets and SEALS stocked for the next ten years.  Or there’s a Federal grant program available only to certain types of recipients.  For example, a grant for EMS may only be available to local government entities or to fire-based departments and will completely overlook private non-profit departments.  Moral of the story?  It often takes a lawyer or at least someone savvy with the ways of government to tap into the “free government money” that the media reports on.  And just as surely as the media will report on two things after this pandemic goes away.  First, they’ll report on some entity that did or didn’t get the money and why that’s a travesty.  Next, when the pandemic stockpiles get recreated and funded, there will be a story within the next two years about “exposing government waste” and a “warehouse full of supplies that no one has ever used.”
2) Failures.  The truth is that COVID-19 is causing unprecedented failures, whether in business or healthcare. And those failures need to be documented and measured so that we don’t make the same mistakes in the next pandemic or disaster.  BUT… it’s also a convenient excuse for failure too. There are stories of deaths being attributed to COVID-19.  At least here in the Lone Star State, death certificates allow for the listing of contributing factors.  So, while COVID-19 might have killed someone, their underlying conditions may have contributed. Or maybe the underlying conditions killed the patient, but the COVID-19 contributed.  COVID-19 might be the cause of death or it might contribute.  This applies outside of medicine too. Lately, I’ve been reading about restaurants “closing due to COVID-19.”  Yes, COVID-19 was probably the final straw.  But if you had a business already in decline, maybe COVID-19 was only the contributing factor.  Or you could have self-inflicted factors caused by your own business decisions. See also the restaurant that refused to allow delivery services BEFORE the pandemic and then closed one of their locations, even for to-go orders, at the first quarantine action by local government. Business, especially the restaurant business, is a Darwinian process with low profit margins.  Relevance to EMS?  I’d also note that EMS is known for low financial margins and is heavily reliant on government funds, as is much of healthcare.  Throwing any disruption into this narrow financial margin and there’s bound to be a financial catastrophe. (See also: nursing homes) In short, it’s always easier to blame an outside event than your own failings and decisions. Case in point being a long time local restaurant deciding to close “due to COVID-19” at the same time that the owner planned to close in the next few months due to retirement and rising rents.
3) And I’ve saved the most controversial post for last.  Let’s talk about quarantines, “stay home, stay safe,” or the popular phrase “flatten the curve.” I am the absolute first to say that COVID-19 isn’t the flu.  It’s a literal pandemic.  And we know that, right now, there’s neither a cure nor a vaccine. As such, we have to take drastic actions to slow the spread of the disease, save lives, and equally importantly, save the foundations of our healthcare system. And to get people to take drastic action, we have to create a sense of urgency. As such, we’ve told people to stay home.  We’ve closed schools and offices and told people to work from home if they can.  We’ve made the decision to take a massive hit to the economy to spare lives and lessen the strain on our healthcare system.  That decision is a no-brainer.  It’s the right decision and it remains so, especially without either a cure or vaccine for this disease. But the models predicting catastrophe have changed and reduced their estimates.  Granted, some places in the United States, like the New York City corridor, have born a terrible price.  (Population density is a real curse in pandemics.) At this point, if ever, we’re unlikely to know if the decrease in deaths is due to our social distancing efforts, better treatment regimens, or a flawed modeling scheme. At some point, whether now or at a still to be determined time, we will have to reopen the country and our economy.  The cure for the pandemic may be the death of our economy.  Clearly, we’re going to have to address this — and smarter minds than my own will have to weigh in.  I am pleased that our political leadership is looking for advice from those outside of the medical field.  While the medicine is crucial in this discussion, my own experience is that the medical community, probably more than any other field I’ve been exposed to, tends to believe its knowledge of healthcare trumps all other concerns and their expertise on health requires immediate deference on all other fields. Regardless, I’ve noticed that our society has changed over the four decades that I’ve been around.  Whether its societal evolution, the 24 hour news cycle, or a climate where social media gives everyone, even the unqualified, the same ability to spread their opinion, we’ve changed. The biggest change I’ve noticed is that our modern society is afraid. We’ve grown to demand safety over all else and find any risk intolerable.  Risk must be mitigated to an infinitesimally small factor. In other words, Karen from Nextdoor has become the avatar of our society.
Sorry for the rambling and the massive diversion from the usual EMS discussions.  Or wait…. maybe this discussion of government, failures, and risk versus safety is EXACTLY what EMS needs to advance.  As I’ve harped more than once, the practice of medicine (including EMS) involves much more than scientific knowledge and clinical skills. Medicine is like engineering or architecture — it applies sciences to human problems.  As such, medicine has to factor in more than the hard sciences.
Thanks for listening.
Filed Under: Law, Politics

Early Lessons/Thoughts From COVID-19 for EMS.

Posted on April 12, 2020 Written by

Because the science is evolving on COVID-19, we know that the end lessons from this may be different.  But I’d like to throw of my early observations out early for consideration.

First and foremost, all of the EMS grants, training, and attention paid to tactical EMS, mass shootings, explosives, and weapons of mass destruction, the real test and draining of EMS has come from an unrelenting call volume brought on by a novel, pandemic respiratory virus.  None of the MOLLE gear and self-absorbed incident command classes are worth much in this.  Except for one aspect of incident command — namely logistics.

Second, we’ve once again learned that EMS has little surge capability. I’ve discussed this before. And most EMS (and fire) services that have transitioned from being rural/suburban combination organizations to small paid departments claim they can rely on mutual aid.  That’s well and good until EVERY system is facing the same demands. Then, you’re waiting for the state and federally contracted providers to deploy within the week.  Maintaining a part-time and/or volunteer program helps relieve some of the stress on the system.

Next, if there’s one key lesson to be learned from this pandemic, it’s that EMS needs better personal protective equipment (PPE) and infection control practices above and beyond parroting the buzzword “BSI.”

In that light, I’d hope that after this, every EMS system makes appropriate PPE available. And that needs to include changes of uniform. (I’ve lost count of how many EMS services think that the part time guy only needs one uniform shirt and nothing else.)

My recommendation for after this is to have an adequate supply of surgical and N95 masks on each rig along with appropriate cleaning supplies. Everyone should get at least 2 complete changes of uniform. Ideally, there should be a couple of pairs of scrubs on board the ambulance/response vehicle in the event you have to decontaminate before returning to the station.

I’d surmise that many of the logistics problems EMS faces stem from two things.  Number one, we stink at public outreach and education.  Most people don’t even think about EMS.  Second. we’re not sure if we’re healthcare or public safety.  That makes it harder for us to access those things reserved specifically for healthcare — or traditionally provided to healthcare organizations.  It took advocacy from the American Ambulance Association to make Amazon’s healthcare specific “store” open to EMS organizations. And at least anecdotally, the public health bureaucracy which administers the majority of the pandemic response often forgets about the needs of EMS. In fact, I’m not unfamiliar with disaster response from both my career in state government as well as my EMS work — and I’m still not sure what, if anything, EMS is getting from the Strategic National Stockpile.

What would I like to see happen?  I’d like to see proper preparation for the next time, because there will be one.  And I’d like to see adequate supplies of both equipment and personnel.  But being an attorney with experience in government, I’m a realist.  And considering this experience. I am cynical enough to have a good guess of what will happen. There will be a massive initial push to get all of this done. There may even be Federal grant money to make this happen. 99.9% of the Federal grant money will be awarded to departments that don’t really need the money. 99.9% of said awarded equipment will dry rot and expire in a warehouse. Some TV newscast will run a story on “a storeroom full of stuff that no one uses” and the stuff will be surplused. Then when COVID-2023 makes its debut, we’ll be right back at square one.

The other thing my cynicism has convinced me of is that the majority of the funds made available for the next pandemic will go to the various public health bureaucracies, certain hospital networks, and the politically connected fire services.  Why?  Because those are the people with the political savvy to navigate the legislative, bureaucratic, and grant processes.

Filed Under: EMS, Politics, Rants

EBM. Do you know what it really means?

Posted on April 8, 2020 Written by

Right now, in this time of COVID-19, there’s a lot of unknowns. There are known unknowns and unknown unknowns, to borrow a phrase from Donald Rumsfeld. Right now, many of those unknowns, both known and unknown, apply to the treatment and management of the disease.  Less than two weeks ago, very educated and skilled clinicians were treating COVID-19 patients like Acute Respiratory Distress Syndrome (ARDS) and intubating patients early and placing them on a ventilator — often with terrible results for the patient  as well as overwhelming the critical care system. As we have increased our understanding of the disease, we’re finding it’s less a ventilation issue and much more an oxygenation issue with a breakdown of iron in the bloodstream.  We’ve gone from intubating patients to laying patients prone with high flow oxygen — not to mention seeing better results.

And like with any emerging issue in medicine, especially when there’s a dearth of known treatments, physicians will try novel treatments, including the off-label use of medications already in use. One of those is hydroxychloroquine, sometimes administered in conjunction with azithromycin. There have been some reports of success of treating COVID-19 patients with this combination, enough so that the President has become a loud cheerleader for this combination.  Whether you adulate, like, dislike, or loathe the current President, no one can deny that he’s a master showman who understands the power of the bully pulpit that being the occupant of the Oval Office gives you.

And because the treatment is being advocated by one of America’s most polarizing politicians, there’s immediate opposition to the combination of hydroxychloroquine and azithromycin.  If you’ve been around any EMS (or even any medical) discussions on social media, especially Twitter, politics routinely injects itself into medicine. There are a lot of physicians and clinicians of all types who feel a joint obligation to both medicine and being “woke.”

Right now, the woke clinicians on social media are opposing this particular treatment regimen in the name of “evidence based medicine,” believing that the double-blind study is the only acceptable evidence of the efficacy of a treatment or medication.  (I’d note that many of these people who poke fun at religion have a similarly blind faith in “science.”)

Yes, the double-blind study is the sine qua non of scientific evidence. I’d like a double-blind study to confirm everything that I do in medicine. But that can be taken to an extreme.  See also the satirical double-blind study of parachutes.

For everyone who blindly opposes new medical interventions based on their own scientific education obtained from the Twitter Institute of Advanced Studies and sharing Neal DeGrasse Tyson memes that repeat the phrase “science,” I’d submit that you don’t know where and how the phrase “evidence based medicine”comes from.  While evidence based medicine, also known as EBM, arose in the medical field for use by clinicians, it rapidly became the watchword of the managed care industry.  In 1985, Blue Cross/Blue Shield began using EBM to evaluate new treatment regimens. In 1991, Kaiser Permanente began using EBM guidelines for treatments.  In other words, the previously science-oriented concept of EBM became a cost control mechanism by implemented by managed care.

In other words, the people pushing the EBM mantra lack the understanding of what EBM is and how it differs from the scientific method.  In science, we should absolutely be pushing for the scientific method.  In an ideal world, we’d have the time, resources, and ability to do randomized double-blind studies on everything we do in medicine.  But we don’t.  And when humans are suffering, maybe sometimes we need to consider ethics in conjunction with a blind devotion to EBM or the scientific method.

Of course, the study of ethics is rarely absolute. It’s full of nuance and variations. And as I’ve discussed before, that’s something that neither EMS nor much of social media excel at. It’s almost like those “core courses” in humanities and social sciences might be a bit more relevant than the Twitter Science Brigade believes.  Neither medicine nor science should have an agenda.  But precisely because social media and the 24 hour news cycle exist, the very term “science” has taken on a political bent.  (e.g. “Science is real.”)

On a final note, while medicine is based in science, I consider medicine an applied science, much like engineering.  Medicine isn’t a pure science.  Rather, it’s the application of science and knowledge to practical problems.  It’s time that we all remember that — and that an education involves much more than science alone.  And science is more than sharing links from Twitter. Science is but one part of a well-rounded education, something which most of the medical world seems to have forgotten.

And that devotion to absolutism in the name of EBM or science is but another symptom of the divided red versus blue world that we’re currently in. Sadly, even a disease like COVID-19 has done little more than highlight the deep divisions in our country.

Thanks for reading.  And we will get through this — just as we got through the Great Depression, World War II, and 9/11.  On that note, “Let’s roll.”

Filed Under: EMS, EMS Education, Rants

EMS Continuing “Education”

Posted on March 2, 2020 Written by

Time for me to bring up a semi-regular rant again. The Texas Bar requires 15 hours of continuing legal education a year, including 3 hours of ethics. Up to 3 hours can be self-study including 1 hour of ethics. And the Texas Bar specifically mentions participating in social media for attorneys as part of self-study.

We all know what our state and/or the National Registry require for continuing education for EMTs and paramedics. And that, at least for National Registry much of it has to be “live.”

Riddle me this, Batman. What’s more educational? Reading a #FOAM article shared by some of the EMS/emergency medicine opinion leaders on social media, discussing low titer whole blood with the actual author of many of studies- or sitting through DVDs of the American Heart Association’s resuscitation awareness schlock or listening to whatever a self-proclaimed “EMS Celebrity” has to say at an EMS conference? While there are certainly concerns about gaming the system, that’s already been a known issue with continuing education, whether it’s people signing off on attending classes they weren’t present for or exceptionally low educational value for certain presentations. (See also: certain EMS celebrities presenting on any topic, regardless of subject matter expertise.)

With the amount of hours required to maintain an EMS certification, I’d say it’s time to start allowing a few hours of FOAM and online participation into the mix.

I’ll commend you to read this article about why we should be embracing #FOAM in EMS. The EMS world needs to embrace the evolution in EMS and medical education by giving credit to those actually looking to improve and advance their professional knowledge versus just sitting through dated material because the state or National Registry says so.

As Dr. Joe Lex says,

  • If you want to know how we practiced medicine 5 years ago, read a textbook.
  • If you want to know how we practiced medicine 2 years ago, read a journal.
  • If you want to know how we practice medicine now, go to a conference.
  • If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM.

In summation, EMS continuing education needs to reflect current practice and actual continuing education as opposed to rehashes of the same dated material that is neither current nor advances medicine.  Neither card courses nor the usual cabal of celebrity EMS conference speakers reflect that.  FOAM and social media often do.  Yet, which gives you actual credit for recertification?

Filed Under: EMS, EMS Education

My Love Hate Relationship With EMS Social Media

Posted on February 18, 2020 Written by

Sorry for the delay in blogging.  None of my usual pet peeves have inspired me to blog as of late.  The truth is that volunteer EMS still has the same challenges and people still put beans in their chili, so maybe I needed to find something new to write about.  And something I shared last week on social media hit me.

I have a love-hate relationship with the internet, social media, and with EMS social media in particular.  I’ve made some incredible friends all over the world, some of whom I’ve met in real life.  Others I’ve yet to meet in real life, but I feel as if I’ve known them all of my life. But there’s also parts that drive me crazy beyond belief, yet I keep coming back to them like the guilty pleasure of watching Jerry Springer or Cops – or the morbid curiosity of looking at a car wreck.  Namely, I keep coming back to the amount of wrong information and/or dogma being spread online.  I used to try to engage and educate and I’ve stepped back a lot from that.  It’s like most debates with the willfully ignorant online: debating online with a moron is like playing chess with a pigeon —  it knocks the pieces over, craps on the board, and flies back to its flock to claim victory.

Image result for someone is being wrong on the internet

So, as a result, I’ve largely retreated and find my pleasure in sharing the stupid privately with like minded friends.  We largely laugh and bemoan the state of EMS and medicine in that such standards are allowed to exist.

The below average person in EMS (who we regularly mock) copes by making fun of patients, engaging in patient abuse, and the like because it’s their crummy coping mechanism for the things they don’t like, understand, or control about EMS. I think a large part of that comes from seeing the same things over and over.  I get that.

For me and people like me, what bothers us seems to be people repeating dogma, those failing to take personal responsibility for their development, and the general low standards out there. I’m as guilty of this as anyone here, if not more so, but I wonder if seeing that dumb behavior has made us cynical and jaded enough that we automatically assume the worst when we see someone post something that seems dumb as opposed to assuming they have a legit question or need for help? Heck, with the benefit of a bit of hindsight, I wonder how many of my questions as a newer EMT or paramedic came across that way.

I start wondering how many legitimate questions get overlooked because of the amount of chaff (IE dogma and mindless repetition) on EMS social media.   A friend of mine asked the same question and recognized that it’s hard to separate real questions from trolling. And then he asked the most important question, “Where do we draw the line at eating our own versus getting rid of an actual problem?”

I don’t have an answer to that.  What I do know is that the “eating our own” will likely continue as long as EMS education’s entry requirements focus on whether the check bounced and whether educational programs see their obligation as producing qualified clinicians as opposed to maintaining an arbitrary retention rate mandated from on high.

As long as retention remains more important than quality, I don’t think EMS social media will see an end to the “How do I pass National Registry?  I’ve failed four times already.” questions.

The challenge for those of us who want to excel in EMS is how to mentor and guide future clinicians without being jaded.  On a positive note, if it makes you feel any better, the attorney social media groups have enough of the same issues that I regularly wonder how some graduated law school or passed the bar exam.

Filed Under: EMS, EMS Education, EMS Social Media

On Rhode Island

Posted on December 18, 2019 Written by

Point of personal privilege here. Because I’m about to rant. And seeing as this is my blog, that’s why you’re here, right?   Sorry, not sorry, that there aren’t any Baby Yoda or cat memes here.

There’s a ton of people posting memes making fun of Rhode Island EMT-Cardiacs and their supposed inability to master advanced airway management.  Most of these memes are being posted by people who like to fashion themselves the fountains of all EMS wisdom and knowledge.  Further, some of these same types believe that their fecal material is non-odorific.

I don’t blame the average Rhode Island EMT-Cardiac for this.  (FYI, for those of you unfamiliar with the certification, the scope is somewhere between Advanced EMT and Paramedic.)  They’re working in a system that they likely didn’t develop.  And at least some, including at least one friend who I’ve literally broken bread with, are competent providers.

I do blame a toxic political culture in Rhode Island where the IAFF, fire chiefs, and politicians hold more sway over the regulation and development of the state’s arguably dated EMS system than do physicians. Rhode Island has its share of EMS issues, including an outsized influence by the fire service, fire chiefs, and fire unions and nowhere near enough involvement from EMS physicians.  Rhode Island’s limited provision of ALS care (EMT-Cardiacs aren’t paramedics.  Sorry, not sorry for that truth.) and it’s relative lack of medical dispatching place Rhode Island severely behind the times in terms of prehospital medical care.

And let’s talk about those snarky edgy social media players criticizing Rhode Island EMS.  They claim to be science-based and evidence-based.  Fine.  I’ll give them that. But what they don’t get is public policy or the political process. Nor do they truly get “just culture,” which is (rightly) supposed to be all the rage in medicine these days.  Nope.  It’s much easier to make memes and make fun of the line-level EMS providers than it is to engage in even superficial analysis and note that Rhode Island’s EMS system and the politics behind it are the problem.

I’ll give Rhode Island credit for one thing.  At least someone in Rhode Island is looking at data.  Granted, the political culture up there is doing what ossified political types do — ducking and distracting, but the data is out there.  I wonder where the data is on actual clinical performance and outcomes for some of these “smarter than you” types posting memes and claiming to be “scientists.”

In summation, for all of y’all who are poking fun at individual EMS providers, I’ll leave you with some lyrics from Ice-T.  “Don’t hate the player, hate the game.”

Filed Under: EMS, EMS Politics, EMS Social Media, Rants

Rural EMS and the Rural Hospital Crisis.

Posted on November 5, 2019 Written by

One of the best pieces of advice that an attorney gave me as I entered the legal profession was that I should read the news every day.  He told me that you never know what future cases might be in the news.  Being a bit of a nerd for politics and policy, I still follow that advice.  This morning’s review of the news led me down a trail where I ended up reading an article from a liberal/progressive publication about rural hospitals in Texas closing.

The article had two accounts of patients dying because a rural hospital in northeast Texas had closed. One patient apparently had a heart attack and the other patient had a brain aneurysm. And the article quoted family members and local politicians as saying that these people wouldn’t have died if the little hospital had still been there.

If you’ve got any experience (or even baseline knowledge) of emergency medicine and EMS in particular, you’ll know that rural hospitals have limited capabilities.  In fact, both of the cases in question likely could  not have been stabilized at a local rural hospital. Both of these patients required extensive specialist interventions that would typically be found in a larger city.  In fact, taking these patients to a rural hospital without specialist capabilities would have actually delayed care.  The well-intentioned laws designed to prevent dumping of patients into an emergency department (EMTALA) would have required the initial hospital to find a specialist facility to accept this patient and then transfer care to said facility. Even in other cases, patients admitted to a hospital may require specialist care or intensive care treatment that is largely unavailable in rural hospitals.

A properly trained, staffed, and equipped EMS system would have been able to recognize that these patients required care well above and beyond local capabilities.  Properly trained and equipped paramedics would be able to provide the same resuscitation and stabilization abilities AND transport directly to the appropriate specialist facility.  As I’ve heard said more than once, there’s no magic resuscitation fairy waiting at the hospital.  Resuscitation measures are the same, whether in an inpatient setting or out of hospital.

The solution to healthcare in rural America is not to engage in a quixotic quest to reopen rural hospitals with limited capabilities and delaying access to definitive, specialist care.  The solution is to channel that funding toward expanded access to primary care, specialists making regular visits to rural communities, and establishing a robust EMS system that provides comprehensive and competent paramedic level care. With an aging population that’s poorer than average, a strong EMS system can absolutely make a difference in rural healthcare. And our EMS voices need to say such.  We are the experts on emergency care outside the hospital.  Period.

Journalists know how to write.  They rarely know medicine.  Or policy.  In this case, their advocacy may well harm patients by delaying definitive care in favor of local care.

Filed Under: EMS, EMS Politics, Politics

The Matrix

Posted on October 7, 2019 Written by

Ever seen The Matrix?  It’s one of the weirdest movies I’ve ever seen.  The folks who created the movie and that entire universe are definitely creative, if not a bit warped.  But there’s a scene in there that applies to EMS.

In the first Matrix movie, Morpheus offers the protagonist Neo a choice.  “This is your last chance. After this, there is no turning back. You take the blue pill—the story ends, you wake up in your bed and believe whatever you want to believe. You take the red pill—you stay in Wonderland, and I show you how deep the rabbit hole goes. Remember: all I’m offering is the truth. Nothing more.”

Reality vs Illusion | image tagged in red pill blue pill,morpheus,democrat,republican,reality | made w/ Imgflip meme maker

The allegory applies to EMS as well. At some point in your EMS career, hopefully early along, you’re offered the choice of the red pill or the blue pill.  You may not even realize you’re being offered this choice, but it’ll happen nonetheless.

For EMS, if you take the blue pill, you’ll be perfectly happy with “meets minimum standards.”  You’ll be able to juggle the inherent contradictions the average EMS provider believes that “we do everything a doctor does, but at 80 miles per hour” and “we don’t diagnose.” (By the way, that’s EXACTLY what doctors, as well as any other clinician, do — diagnose.) You’ll believe that the less than 200 clock hours of training to become an emergency medical technician (EMT) represents a significant level of professional achievement and that such a level of “achievement” qualifies you to “save” your paramedic partner regularly.  In short, you’ll become blissfully ignorant and perfectly happy working the dialysis shuffle and keeping the EMT t-shirt manufacturers in business.

OR…. you can take the red pill. You can learn evidence based medicine.  You can learn the science behind what we do.  You can begin to understand the outside factors that impact EMS — law, politics, and policy.  God forbid, you might even understand that there’s no one single bullet that will fix all of EMS’s problems.  We’ve tried EMS 2.0; we’ve tried “community paramedicine;” and now we’re on the “EMS needs degrees” kick. Truth is — we probably need all of those things to make EMS great again.  And probably some more things need to happen to truly fix EMS.  BUT, you have to be willing to accept the knowledge and education.

Pardon the change in allegory here, but when the snake offers you the forbidden fruit with the gift of knowledge and you eat it, you open your eyes.  And to add one more allegory, you might even see that the emperor has no clothes.

Somewhere along the way in my EMS career, I was fortunate enough to be around some educated and wise folks in prehospital medicine who offered me the red pill and the forbidden fruit.  I opened my eyes and realized that this is the practice of medicine and that it’s a constantly growing field whose only certainty is the growth of that which we don’t know.  I learned to embrace nuance.  I learned to embrace learning.  I think I’m better for it.  And I’d like to hope that some of my patients are better for it.

What would’ve happened had I chosen to take the blue pill and remain complacent, ignorant, and blissful? I’d have been “happy” riding an engine as the token EMT at a volunteer fire department that ran 1-2 calls a shift and where learning wasn’t encouraged. Ignorance would have been bliss.

But would I have truly grown?  Nope.

Do I have regrets?  I absolutely do at times. There are times when doing the right thing isn’t easy. There’s also knowing when to pick your battles.  Anyone who knows me knows that’s a continuing challenge for me. Would I take the same choice again?  Also, yes.

For each of you, there’s a choice each day you practice prehospital medicine.  I hope that you take the choice to stay in Wonderland and see how deep the rabbit hole goes.  You, your patients, and our profession will all get better.

 

Filed Under: EMS, Rants

The Paramedic Shortage

Posted on September 24, 2019 Written by

My good friend (and I daresay mentor) Dr. Bryan Bledose recently opined on the paramedic “shortage” in the United States.

The good doctor mentions several ideas worthy of consideration, including limiting the number of paramedics, improving the scope of basic and intermediate level providers, and allowing for transport to alternate destination.  And like many of the current discussions, he advocates a college degree for paramedic level providers, which is a cause that I can support, given the requisite forethought and groundwork prior to a requirement being instituted.

I really don’t know if the numbers support the assertion that there is a shortage — or that there isn’t.  What I do believe is that a degree requirement is going to exacerbate a shortage.  There’s all the usual arguments that the fire service won’t embrace a degree and that rural EMS will suffer from a lack of access to educational programs.  And the truth is that those are valid concerns.

 

But here’s my real concern. Most all of us know and agree that a college education creates a more well-rounded provider and provides a core curriculum in English and the humanities.  (I’d also note that said core curriculum is one of the least recognized benefits of a college education from many of the loudest EMS degree advocates on social media.)

 

We also know that many EMS organizations are poorly managed and have a toxic organizational culture. How many degree educated paramedics are going to stick around this average EMS workplace with the toxic culture and idiotic management? There’s a lot better places to work much of the time and a degree educated provider is typically educated enough to recognize this. College educated folks are a bit less likely to want to drive a truck around town for twelve hour shifts and eat and perform their bodily functions at the nearest 7-11, depending on the whims of dispatch.  And a college educated professional is unlikely to respond well to unwritten policies and upper management dictating policy through email rants.

If we want to fix EMS and address the paramedic shortage, we need to address working conditions first. And that starts with expecting EMS managers and leaders to actually be competent to run a functional organization.  EMS needs more education, but that education needs to extend well beyond a better way to read an EKG.

Filed Under: EMS, EMS Education

And So It Goes

Posted on August 14, 2019 Written by

Years ago, my friend Mike Levy used to close out his email blasts on local politics with “and so it goes,” implying his despair that things would change or improve.  This morning, I happened to see an EMS colleague post a cartoon about how everyone wants change, yet no one seems willing to change.  Below are my thoughts on where we’re at in EMS.

 

We hear a bunch of people say we need the next generation of EMS leaders step up. Then we step up and we’re told to wait our turn, bide our time, and not speak until spoken to. Meanwhile, the people who created the problems of modern EMS are on all of the blue ribbon committees and consulting teams to fix the problems they created in the first place. Tact prevents me from naming names, but if you’ve been around EMS for more than fifteen minutes, you’ll recognize the names of what Mad Magazine called the “usual gang of idiots.”

And of course, as is the trend in modern politics, EMS continues looking for the single solution that will fix all that ails EMS.  A few years ago, it was community paramedicine.  (By the way, yours truly still thinks that knowing how to navigate the healthcare and social services systems and pointing patients to the right resources is an essential skill for a medical provider of any sort.)  Now, the latest push for EMS success has been distilled into a single catchphrase: “EMS Needs Degrees.”  It may not be as catchy as Bernie Sanders’ catchphrase of “Medicare For All,” but it’s equally simplistic and just as poorly thought out. Almost no one in EMS has thought out how a degree requirement would work, what such a degree would contain, or even found out if the higher education system(s) have the ability or desire to take on the task of educating paramedics. (Hint: Part of the nursing shortage relates directly to a shortage of qualified nursing faculty.  Considering how few in EMS already have EMS specific degrees, I can’t help but think that the shortage of qualified faculty to teach paramedics at the college level will be even worse.) And now, we have the first state proposing an actual degree requirement for EMS, namely North Carolina, which will require an associate of applied science in EMS to obtain paramedic licensure.  For many people and in many situations, this degree will be the end of their higher education journey, at least in part because the AAS curriculum rarely transitions well to bachelor’s degree requirements.  Once again, EMS looks for an easy fix to a complex problem.  As I like to say, good public policy can rarely be distilled to a meme or fit in a single Tweet.

The issues with EMS are complex and heavily tied to public policy, namely how the Federal government’s two financing mechanisms, Medicare and Medicaid, pay EMS as a transportation service as opposed providing healthcare.  That also explains why the historical option for EMS care is to offer a ride to the hospital emergency department.  But right now, instead of recognizing the need for future EMS leaders to have some concept of management, finance, politics, and public policy, we’re confining what constitutes EMS education to a set of technical skills. (I truly think that some of the loudest voices on EMS social media advocating for a degree are basing what an EMS degree should be on a wish list of skills and technology they’d like for an ambulance.  I’d also note that’s not how most educational models work aside from trade or vocational school.) We are not even guaranteeing that EMS providers are educated in the arts and sciences to understand the hows and whys of medicine and the context in which prehospital medicine fits into everything else.  And going back to my earlier comment about the current crop of so-called EMS leaders not wanting to relinquish their positions — you couldn’t think of a better way to keep the “new kids” out of leadership than to deny them the actual skill set and education they need while claiming that you’re helping the profession advance.

And so it goes.  Indeed.

Filed Under: EMS, EMS Education, EMS Politics
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