The Soft Bigotry of Low Expectations

Yes, I know that’s a quote used in a George W. Bush speech.  Yes, I know some of you may not like President Bush.  Truth be told, I don’t always either. (He’s like the Diet Coke of conservatism: Just one calorie, not conservative enough! — Apologies to Dr. Evil, by the way.)

But, truth be told, it’s a quote that applies so well to EMS.  I’ve been guilty of it myself.  And I think a lot of us are incredibly negative about EMS, our past, and our future. Day after day, I read posts on EMS social media about provider mental health.  I read posts about the pay in EMS.  Heck, I even read posts about poor EMS protocols, poor working conditions, and poor coworkers.  When you read that, it’s easy to get discouraged about EMS.

Here’s the great news.  Provider mental health is an issue.  But we’re addressing it.  The Code Green Campaign is raising awareness, promoting access to mental health care, promoting resiliency, and promoting self care.  Reviving Responders is doing similar work as well.

As for the other issues, there are solutions.  Forming associations to represent our profession at the state capitols where the majority of EMS regulation occurs is a huge step.  Yesterday marked the one year anniversary of my state’s EMS association, the Association of Texas EMS Professionals.  In that year, we’ve accomplished a lot – from providing paramedics the ability to work in hospital ERs to being recognized as the state affiliate of the National Association of Emergency Medical Technicians to being called to testify before the Texas Legislature as witnesses on EMS issues.

For those of you complaining about poor pay, poor working conditions, and poor protocols, there are services out there that are looking for EMS professionals like you.  It may involve getting out of your comfort zone, but these places exist — all over the country. At the risk of sounding like “tough love,” if you choose to still work for a bad employer, you have made your choice.

And yes, there are places where learning happens.  Social media may have its faults (see also: EMS “clickbait” articles), but the FOAM (Free and Open Access to Medical Education) movement is bringing current medicine to all of us.  Granted, much of it is geared to emergency physicians, but we should be learning at their level anyway.  Medicine is medicine.  EMS remains the only profession with arbitrary concepts like BLS and ALS.  While there may be regulations governing scope of practice, I’ll give you some free legal advice.  THERE IS ZERO LEGAL LIMITATION ON EXPANDING YOUR KNOWLEDGE.  Other learning opportunities exist at EMS conferences.  If you are only learning your profession from within your department, you’re selling yourself and your patients short.  Insular clinical thinking and inbreeding in education is a disservice to our profession.  Professional networking and exposure to new, outside ideas is how change happens in EMS.  And there’s even opportunities to expand one’s EMS horizons on Facebook.

So, in conclusion, I’ll leave you with another cliché politicized quote that also applies to what we do in EMS.  “It gets better.”  And it starts with each of us.  Go. Do. Medicine.

Have you ever noticed….?

Have you ever noticed how many new, inexperienced, poorly educated providers talk about how much they’re allowed to “do” in their EMS organization/system/region?

Today, I was involved in a discussion in EMS social media where an EMT with three months of experience was bragging about taking a sixteen hour course where he would get “training” on administering three additional medications and be allowed to use a supraglottic airway. In the grand scheme of things, all of these medications and the supraglottic airway are relatively benign interventions.  There’s relatively low risk for each of the medications and the airway device in question. What is NOT benign is the prevailing mentality in EMS that a card class or an in-service is all that’s needed, especially to teach an entry-level EMS provider skills that are normally reserved for providers with a higher certification. Even with its numerous faults, paramedic education has a depth of education in anatomy, physiology, pharmacology, and patient assessment that an EMT or AEMT course don’t have. While a sixteen hour course might be able to teach the ins and outs of those particular medications and that particular airway device, that course is zero substitute for actually having the education that an advanced provider has.  We can teach almost anyone how to do something.  Knowing when to do something — or when not to do something — is where education is superior to training.

Sadly, our profession has done little to disabuse EMS providers, especially inexperienced entry level providers, of the notion that EMS consists only of a set of skills that can be added and subtracted at whim.  Rather, like any academic discipline, particularly one involving the healing arts, EMS consists of knowledge.  And there is no statutory limit on the knowledge that any provider can have, regardless of their certification level. Professional education does not end with initial certification.  Rather, initial certification is but a determination of entry level minimal competence.  Professionalism involves the relentless pursuit of mastery well above and beyond the minimum standards.

As I’ve joked before, a cook knows and follows the recipes.  A chef understands the culinary arts well enough to be able to create their own recipes.  The majority of EMS providers are technicians — and as such, we’ve become the short order cooks of medicine.

EMS will become a respected part of the medical system when we stop talking about what we can do and start talking about what we know.  There’s a big difference between training and education.  When we routinely produce educated clinicians as opposed to trained technicians, that’s when the respect — and the money — will show up.

It’s Never About the Pay

Years ago, as a new attorney working in state government, I worked for a state agency that determined they had a problem retaining attorneys.  They did a lot of surveys, most of which revealed discontent with working conditions.  The reality was that management used junior attorneys as glorified paralegals and gave them little professional discretion and routinely micromanaged.  Of course, management did not want to hear this.  Instead, a new pay scale was issued, which gave everyone an immediate raise and also decreased the time before being eligible for the next promotion.  Management made the decision that it was easier (and possibly cheaper) to give everyone a raise than improve working conditions.  Needless to say, the retention improved, but only slightly.  At that point, I told one of my colleagues, “It’s never about the pay.  It’s about what people are willing to put up with for that pay.”  People know the salary when they accept a job.  What they don’t know is what the job is going to be like.

But my blog is (usually) about EMS and my EMS experiences.  What does this have to do with EMS?   Everything.  We routinely hear that there’s a shortage of EMS providers.  We regularly are inundated with stories about a shortage of volunteer EMS providers. There have been numerous committees studying the issue of a perceived shortage of providers.  Some states have done a terrible job of promoting becoming an EMT or paramedic.  The Pennsylvania “Roll With It” campaign comes to mind.

What remains is a shortage of EMS providers willing to put up with the working conditions made available to them at the salary offered.  And this is even more the case for EMS volunteers.  I will fully admit that as a volunteer medic, I will put up with relatively little BS in return for providing free paramedic care.

So, to those of you wondering where your volunteers are or why you aren’t keeping volunteers, I’ll ask you a few questions.

  1. How easy do you make it to volunteer?   Is your application online?  Do you have a point of contact?  Do you even have a webpage?
  2. How soon can you get people on shift?  Is the process tied up with committee meetings, orientations, and other obstacles?
  3. Do you provide the volunteer everything they need?  Or do you make them spend money out of pocket on uniforms?
  4. Do you have an open, transparent on-boarding and field training process?  Or does your training staff regularly play “hide the ball?”
  5. Do you truly make your volunteers part of the team?  Or do you make things difficult (even unintentionally) and say “we’re holding you to the same standards as everyone else?”
  6. Do you have some flexibility in the process?  Or do you rigidly refuse to deviate from your processes?
  7. Do you truly welcome new people?  Or do you have cliques and the “old guys” club at your station?
  8. Do you welcome those with prior experience? Or do you force them into a model of starting from scratch because your organization is “special?”
  9. Do you learn from previous issues?  Or do you act as if “this is the first time we’ve heard about this?”
  10. And finally, have you told your staff (both paid and volunteer) that they’re appreciated?  More importantly, do you back those words up with action?

There’s not a shortage of EMS volunteers.  I know many people with EMS certifications who’d like to get back on the truck.  The real shortage is the number of EMS organizations that truly want and appreciate providers, whether paid or volunteer.

Fight For $15

So, in a fit of rage, I was almost tempted to write a screed about how EMS providers don’t deserve the $15 per hour wage that fast food workers are protesting and clamoring for. My rationale was (and remains) simple.  After watching the attitudes from so many EMS providers, especially in the average online discussion, I’d be hard pressed to argue that many people in EMS deserve to be paid this much even.  Whether it’s the blind devotion to dogma (See also: Spinal motion restriction), the overinflated sense of self importance (See also: the usual t-shirt slogans about how under 200 hours of first aid training is equivalent to being a physician), or the culture that mocks education (See also: The usual claptrap about EMTs saving paramedics and/or “BLS before ALS”), it’s clear that many people in EMS are overpaid at minimum wage.

Today, though, I dug deeper into a recent EMS discussion about the priority between hemorrhage control and the classic “Airway, Breathing, Circulation” priorities that are drilled into almost every EMS provider.  I noticed that the majority of providers wanted a definite, absolute answer.  They wanted a clearcut answer.

Here’s the problem.  In any learned profession, whether it’s engineering or medicine, the answers are rarely clear.  Answers to most questions are heavily dependent on both the facts of the situation and the judgment of the professional.  As both an attorney and a paramedic, my favorite answer to any question is, “It depends.”  But too many of us in EMS want a definite answer.  We want a protocol or a flowchart to follow.  We claim that we want to be treated as professionals, but then we want someone to supply us the answers and make it easy for us.  Following the protocols or the skills sheet truly is the medical version of being a fry cook.  Congrats!  We’ve earned our $15.



About Orlando, Paris, San Bernadino, and Everyplace Else

Knowing me, I’ll bet you thought this would be about gun control.  Nope.  If you know me, you know where I stand. I’m not going to convince those who disagree with me and they’re unlikely to change me either.

What most of us agree on is that we have to DO SOMETHING.  I agree.  One death from violence is one too many.  And then, my good friend Kelly Grayson made a post on Facebook that inspired me. Kelly suggested that so many people in Orlando didn’t have the training or tools to provide lifesaving care.

Then it hit me.  We in EMS and the medical field have been encouraging the public to learn CPR and how to use an AED.  We’ve been doing it for years to help save lives in cases of sudden cardiac arrest.  It’s time to do the same for bleeding control.  Just like in sudden cardiac arrest, severe bleeding is a time-sensitive emergency.  By the time that EMS arrives, the patient may be dead.  Just like in sudden cardiac arrest, bystander care can change the dynamic.

The National Association of EMTs offers a class called B-Con that addresses simple strategies for bleeding control and initial airway management.  The class is designed for and is appropriate for the general public. In the event of another tragedy of violence, it’s quite likely that medical providers won’t enter the scene until law enforcement has controlled the threat.  In Orlando, that took over three hours.  It will literally take minutes to bleed to death from an uncontrolled severe hemorrhage.  With the military’s training on bleeding control, shock management, and initial airway management, I’d argue that right now, your chances of surviving from being shot in a combat zone are better than for the average civilian.  That has to change.  And the change begins here.  Now.

Until the possibilities of violence and accidents are eliminated from the world, which is an unlikely proposition, we need to make the knowledge and tools to stop bleeding as accessible as CPR and AEDs.  The public needs education on stopping bleeding and access to bandages and tourniquets.

The skills to save a life are accessible to the general public.  EMS professionals have the tools to teach these skills.  Let’s make it happen. This.  This is how we do something.  This is how we remember Orlando, Paris, San Bernadino, Newtown, and everyplace else.


Time To Call It Like I See It

In my EMS career, I’ve been very fortunate for two things.  One, I’ve had the opportunity to work for some great EMS systems.  Two, by virtue of my outside career, I don’t have to rely on EMS to make ends meet or pay the bills.  To me, that also means I have an obligation to speak my mind about EMS, especially since many of my colleagues don’t always have the luxury of being able to speak theirs.

Today is one of those days where I’m going to speak my mind and say it as loud as I can. A few moments ago, I saw a social media post from a large EMS publication.  The post was entitled “Addressing Ten Harmful Realities of Modern EMS.” Plain and simple, I’m not going to link to it.  Here’s why.  To be honest with you, this article was written by an EMS consultant who’s been involved in the EMS world for years.  The article is published by a major EMS publication.

In short, we’ve got the same usual suspects of the same usual EMS columnists, the same usual people who are on every EMS committee, the same EMS publications, and the same EMS consultants telling how to fix the problems in EMS that, in large part, they’ve helped create and/or perpetuate.  At the very least, they’ve been complicit in not addressing them for a damned long time.

The main EMS publications aren’t peer reviewed.  They consist largely of reprinting advertisements for products.  The “science” they post is largely dated and the truly progressive EMS systems (the ones that aren’t busy tooting their own horns) have been ahead of the curve established by the EMS publications for a long time.  I can guarantee the pictures that’ll be shown in the same publications every month: namely a picture of fire-medics somewhere on the East Coast of the US, wearing full bunker gear, working a “scary looking” car wreck, and putting everyone on a backboard.  It’s at the point that several of my smarter friends have nicknamed one publication “Backboard Action” and refer to many EMS publications as “backboard porn.”  And mind you, the science has been trending away from the spinal motion restriction dogma for a while. Our EMS media isn’t the “conscience of EMS.”  It’s little more than a cheerleading section for the self-promoters of EMS.

The article goes on to talk about working conditions in EMS.  My friends, this article is written by an advocate for many of the practices that have created these working conditions.  If you like poor pay and system status management where you park your ambulance in an abandoned parking lot at 3:00 AM because that’s where the computer predicts coverage is needed, then, by all means, continue listening to the same people try to fix the problems that they’ve created.

The same people who’ve brought us these working conditions are the same people who continue to limit the knowledge base and educational standards of EMS.  Whether they use the “poor volunteers” or the fire service as their excuse, they continue to keep the same low standards and low expectations guaranteed to “meet minimal standards” and keep EMS down.  If you wonder why the best and brightest leave EMS for nursing or medicine and why the barely competent become EMS managers or educators, look right at the same EMS committee members who continue to pass on the chance to improve our educational standards or knowledge base.

And let’s talk about the medicine.  Let’s talk about the science.  That gets defined by our professional committee members and celebrity EMS medical directors.  Every year, there’s a “Gathering of the Eagles” where a bunch of celebrity EMS physicians present their opinions.  The Eagles, in theory, represent the fifty largest EMS systems in the country.  Large doesn’t equal great.  Far from it.  The District of Columbia, New York City, and Los Angeles aren’t exactly renowned for their quality of prehospital care. These presentations have a strong bias toward cardiac arrest.  While cardiac arrest is, in part, what EMS was started to fight, cardiac arrests represent a small portion of EMS responses.  Cardiac arrest gets studied because “dead” or “not dead” is easy to quantify.  Let’s talk about pain management.  Let’s talk about airways.  And let’s not dumb down the medicine because you have a large system of providers and it’s “too hard” to roll out training or keep quality assurance and quality improvement on “so many medics.”

A special mention to the majority of the EMS conferences as well. I’ve spoken at several, primarily state, conferences.  I’ve been fortunate in that these people are usually willing to let me speak my mind on a variety of topics, usually related to the law in EMS.  But the national conferences seem to represent many of the problems in EMS as well.  Namely, you’ve got “EMS celebrities” presenting topics that are either “fluff” or represent science that is already so well-established that it’s borderline negligence to not already incorporate it in your practice.  When speeches entitled “A Pressure Dressing For the Soul” or “Incorporating CPAP into Your Practice” are major speeches, the problem is clear.  By making everyone feel good about themselves and their practice of medicine, you may get “butts in the seats” but you’re sure not advancing the profession.  Just once, I’d pay good money to have someone present on the Dunning-Kruger effect and its applicability to EMS. Instead, we get feel good platitudes from someone dressed in a uniform that looks like a third world dictator.

In other words, the same people doing the same things in EMS aren’t going to fix it.  But I’m optimistic.  And here’s why.  New people in EMS are stepping up to the plate.  They’re recognizing the challenges in EMS.  And they’re advancing them, even when the usual gang of idiots tell them it’s pointless.  In 2014, two medics, who happen to be friends and inspirations to me, decided that EMS provider suicides were unacceptable.  They formed the Code Green Campaign.  Several other medics I know also decided to tackle mental health in EMS as well.  They formed Reviving Responders. And in 2015, when the Texas Legislature faced opposition from emergency nurses about allowing paramedics to function in the hospital, several Texas medics started talking on social media, shared the news, and formed the Association of Texas EMS Professionals to advocate for Texas EMS in the political arena.  The issue is not whether EMS can improve.  It clearly can.  It’s just time for us to recognize that what Mad Magazine calls “the usual gang of idiots” aren’t going to get us there.

To the younger EMS providers, I say, this is your time.  Stand up and lead EMS because the dinosaurs have failed to evolve and are doomed to extinction.  There is ZERO reason why EMS can’t become a respected medical profession entrusted to perform advanced assessments and interventions in the prehospital setting.  The only thing preventing this is that we’ve selected the wrong leaders.  Probably more accurately, we’ve been passive and allowed the wrong people to claim to speak for EMS.

Thank you for reading and for allowing me to be a voice out there.

On Fire and Medics

Recently, a lot of my Canadian EMS friends and colleagues have been concerned about proposals for Canadian firefighters to provide emergency medical care.  In much of Canada, prehospital care is exclusively the province (pardon the pun) of EMS and the fire service plays a limited role if it’s even involved at all.

I’ve been involved in a variety of EMS systems. I’ve probably observed even more EMS systems.  The general rule of thumb is that if you’ve seen one EMS system, you’ve seen one EMS system.  EMS systems and the delivery of prehospital medicine is a very local phenomenon, particularly in the United States.  What works in New York City probably won’t apply to rural Iowa, the Big Bend of Texas, or even the casinos in Las Vegas.  Having said that, I’m going to go ahead and give some general conclusions on the idea of fire-based EMS delivery.

Number one, I don’t have a single problem with firefighter paramedics.  I’ve seen some first rate fire medics who are current on the science and share a strong commitment to prehospital care. However, I’ve rarely seen a large urban fire department that actively has a commitment to excellence in emergency medicine. While a large department may have budget issues, this rarely seems to hold them back from buying new fire apparatus and equipment while the EMS side of the station soldiers on with equipment that most likely meets minimum state licensing standards. When you have departments that view “being on the box” as either punishment or a ticket to be punched for promotion, patient care stagnates and suffers.  When you have company officers saying things like, “You think too much like a paramedic,” the message is clear — medicine isn’t important to the fire service.

The same firefighters that share hashtags like “Always Training” and “All Hazards” while they train on the Denver Drill or SLICERS are often the same guys who “don’t need to know it” when the latest medical guidelines come out.  The same guys who attend FDIC and every IAFF event are the ones least likely to be at an EMS conference like EMS World Expo, EMS Today, or their state EMS conference. Tell me the last time you’ve seen a fire department’s Facebook page showcasing the EMS training that their firefighters go through?  Contrast that with the constant barrage of social media posts showing structural firefighting training (and operations) and it becomes clear that most departments don’t consider EMS part of their core mission.

In a certain urban fire department, there was a rivalry between the special operations team and the rest of the suppression side of the department that was summed up with “90/10” — doing ninety percent of the work and getting ten percent of the credit.  Sadly, the same ratio probably applies to the EMS side of the fire station.

I don’t have a problem with firefighter/paramedics.  I do have a problem with the fire service EMS culture. This pains me, because I truly love the fire station culture of brotherhood and camaraderie, even if it’s not always perfectly expressed.  I’ve had some of the best meals and some of the best conversations at a fire station dining table. If the culture refuses to change, then it’s time to keep fire and EMS separate.

No firefighter should be required to be a paramedic.  And neither should a paramedic be required to be a firefighter.

If you have to ask whether this blog applies to your fire department, then I hope to see you at the next EMS conference.

We Deserve Respect?

At every gathering of EMS providers, whether in person or in the online world, we constantly bemoan the perceived lack of respect that the “ambulance drivers” get from the rest of the medical community, from other public safety providers, and from the public that we serve.  So, to answer the question as to “when will we get the respect that we deserve,” I present the following answers.

When doing the right thing for the patient becomes more important than doing something, no matter what it is.

When we embrace education and science-based medicine rather than dogma because “our instructor said so” or “I’ve seen it work.”

When we work constantly to raise the minimum standards for entry into EMS rather than continually watering down standards while using “the volunteer crisis” as an excuse.

When we spend as much on continuing education and pursuing knowledge as we do on getting another set of LED lights for our personal vehicle.

When we embrace professional self-regulation rather than being an afterthought in most states’ health and human services bureaucracies where the same people inspecting ambulances are inspecting tattoo parlors and tanning beds.

When the term “semester” replaces “clock hours” for ALL levels of EMS education.

When we recognize that patient advocacy and customer service are part of the job rather than something to be ridiculed with a t-shirt slogan.

When we realize that completion of a 120-180 hour EMT course and passing a test of minimal competency is but the beginning rather than the pinnacle of a medical career.

When we recognize that heroism consists of significantly more than merely working in the emergency medical field and doing your job.

When punitive medicine like selecting IV catheter size based on your annoyance factor with the patient or joking about rapid sequence intubation of a patient without adequate sedation is no longer accepted on your ambulance. (At the very least, can we not make these comments in a setting where the public can hear them?)

When shop-worn slogans denigrating advanced practice in favor of “BLS before ALS” are recognized as the anti-intellectual attitudes that they are.

When EMS education reaches a point where one can become a paramedic without first having EMT certification.  Doctors didn’t go to physicians’ assistant school first and lawyers don’t have to become a paralegal first.

When we recognize that “street experience” may actually be meaningless if it was three years of working a BLS transfer truck and learning nothing but bad habits, shortcuts, dogma, and who gives free coffee to EMS.

When we realize that the most important thing that any EMS provider can do is to provide a thorough, competent assessment rather than some “sexy” skill.

When we stop using “the lawyers” as a mythical bogeyman and start understanding the laws and regulations that impact the practice of prehospital medicine.

When we as EMS providers have a voice at both the US Capitol and each and every state capitol.

When our goal is that we leave every patient at least as well as we found them.

When we stop defining EMS by “what we can do.”

When we realize that we DO diagnose and that diagnosis is not illegal, but rather, is expected.

When we recognize that what’s not an emergency to us is still the most important thing that’s happened to the patient today.

When we realize that the most important person in the room is the patient.

When we cease to define clinical competency by parroting a skills sheet.

When EMS managers cease to define success by response time and cardiac arrest survival.

When every EMS provider in every EMS system knows who their medical director is and how to reach them.

When we realize that continuing education is designed to teach new concepts rather than just merely repeating the same dogma on a two year basis.

When we recognize that lowest common denominator medicine means that providers will sink to the lowest common denominator.

When we finally realize that the biggest obstacle to EMS advancement is the average EMS provider.

When we recognize that it’s not our job to judge our patient, but it is our job to treat our patient.


When we can hit even fifty percent of these goals, the respect will be earned.  And so will the salary.

Closing Out EMS Week

As we close out EMS Week 2016, I thought I’d share some more thoughts and observations as you digest your snacks from the break room and enjoy your party favors with the pre-printed motivational saying on it.

Yesterday, on Facebook, a good friend shared a post that I modified and shared.  I think it’s worth sharing here as well.  I’d like to thank the people who’ve made EMS Week possible for me. Thank to the instructors who made it possible for me to get my EMT and then paramedic certification. Thank you to the mentors who’ve inspired me over the years. Thank you to the coworkers who’ve partnered with me over the years. Thank you to the managers, supervisors, and medical directors who’ve put up with way more from me that you should have. Thank you to my family and friends who’ve always supported my passion for EMS. A special thank you to my non-EMS employers who’ve been supportive of my extracurricular EMS activities and given me the time off to pursue them. And finally, thank you to each and every patient who’s trusted me to care for them. There’s too many of you to mention by name and I wouldn’t want to overlook everyone, so please know that each of you has made it possible for me to enjoy both EMS Week and every shift I get to work.

To top yesterday off, I came home and found the latest edition of Dr. Bryan Bledsoe’s paramedic text waiting for me, courtesy of UPS. Spoiler alert: the medical-legal chapter is co-written by yours truly. The biggest thing that we can do in any profession is to pay back the mentoring we’ve received along the way.  I don’t get out on an ambulance nearly as much as I’d like, but I make it a goal to leave EMS better than I found it.  And the biggest impact I can make is to improve EMS education.  In my case in particular, I’d like for EMS students of all levels to have an understanding of the law relating to prehospital care as opposed to myths and urban legends about EMS legal issues.

I’ll leave you with two thoughts as we close out EMS Week 2016. One, the perfect EMS system is much like the Loch Ness Monster. Everyone is looking for it and no one has found it. Strive to make your EMS system the best it can be and find out what you can live with for the pay. (It’s never about the pay.  It’s ALWAYS about what people will put up with for the pay they’re given.)  Thought number two:  If we’d spend 25% of the time that we spend complaining about being called “ambulance drivers” on actually improving EMS, we’d find that, in a very short time, we wouldn’t be called ambulance drivers.

Another EMS Week Post

Well, it’s Monday and it’s the annual commemoration of EMS Week.  This is the week where you’ll likely get some sort of junk food at the local ER, assuming the staff doesn’t eat it first. Your employer may give you some sort of trinkets and there will probably be a couple of extra motivational posters around the station.  All of those are the traditional ways of celebrating our week and honoring what we do for our respective communities.

But I wanted to go a little past that.   I saw something last week that got me to thinking.  Last week, I saw pictures of a bunch of paramedics from a large EMS system undergoing boot-camp style training to become “rescue” paramedics, skilled in rope and water rescue.  And that led to another thought – namely, how many of us add something else to modify the term EMT or paramedic.  Firefighter/EMT.  Special Operations Paramedic.  Critical Care Paramedic. Firefighter/Paramedic. Flight Paramedic. Dive Medic. Community Paramedic. Firefighter Paramedic. Tactical Medic.

It’s absolutely great — and essential — to expand our knowledge and, in some cases, to expand what EMS does to meet our respective communities’ needs. However, the reality is that each and all of those roles fill limited needs.   There are relatively few patients that need advanced life support provided by paramedics rappelling down a cliff or that need care under fire (at least in the civilian world).  The chances of needing to intubate a patient in a radioactive environment are pretty close to nil.

Let’s go back to the famed “White Paper” issued by the National Academy of Sciences in 1966.  That’s the paper that gave the impetus for modern EMS.  It addressed accidental death and disability in the out of hospital setting. From that, EMS has evolved into the practice of prehospital medicine.  To me, what EMS is delivering the practice of medicine, outside the clinical setting, incorporating some aspects of the public safety disciplines to do so.

There’s nothing wrong whatsoever with these additional skill sets.  What is wrong is the explanation that I’ve heard from some of these providers as to why they pursue those skill sets. Time and time again, I’ve heard, “I wanted the additional challenge.”  My continuing belief is that if you do the medicine right, there’s plenty of challenge. Medicine is constantly evolving.  The clinical practice of medicine has changed dramatically in the twelve years I’ve been in EMS.  More and more EMS systems have embraced selective spinal motion restriction, rapid sequence intubation, 12-lead EKG interpretation, and standing orders for pain management.  When I first entered EMS, I’d never heard of ketamine or sepsis, yet both of these are now routine terms I use in my practice of medicine.

On this EMS Week, let’s each make the commitment to each and every one of our patients by doing the core mission that unites us all — providing the best medicine possible. On this EMS Week, commit to being a clinician first and foremost.