What Might Be Wrong With EMS and EMS Education

Earlier this week, I was speaking with someone in the EMS regulatory world and they mentioned having to possibly roll out a class on a new infectious disease concern.  I began to wonder if part of the problem is that many EMS providers are technicians who are taught to “fix” a patient’s “condition.” Every so often, the latest buzz hits EMS and we all roll out something “new” to address this.

Some years, the EMS flavor du jour is anaphylaxis.  Some years, it’s been cardiac arrest.  Some years, it’s been acute coronary syndrome.  Yet other years, stroke becomes a focus. Currently, we seem to be torn between sepsis and emerging tropical infectious diseases (Ebola and now Zika).  All of these are important topics and something that any EMS provider should be capable of at least beginning to address. Meanwhile, we have all of the various factions advocating that EMS will get the respect it deserves if we go into “community paramedicine,” “tactical medicine,” or “critical care paramedicine.”  Then factor in the various advocates pushing differing models of EMS, whether private, third-service, or fire-based.

Yet, what everyone is overlooking is simple. We’re teaching EMS providers the recipes for cooking, but not how to actually cook.  Every one of these new ideas that rolls out fails to address the simple fact that EMS providers aren’t taught the fundamentals of medicine.   Teach anatomy, physiology, pathophysiology, pharmacology, assessment, and skills appropriate to the provider level.  If you taught the core fundamentals of medicine rather than flowcharts and protocols, you’d have an educated provider who, at any level, is capable of adapting and providing clinically appropriate to almost any patient.

If you teach a chef, you teach them their way around the kitchen.  If you train a cook, you teach them how to make things from the recipe.  In EMS, we’re turning out short order cooks who need a new recipe anytime the clinical tastes change as opposed to professional chefs who know how to make a recipe of their own and can vary that recipe for their patient/customer. And until we fix that, all of the latest card courses and “urgent” continuing education modules to address the latest problem won’t fix the real problem with EMS.


A Next Step in EMS Provider Safety and Health

Over the last few years, EMS provider safety and health has come to the forefront.  Rightfully so. Whether unreported, under-reported, or just ignored in the past, we’ve recently begun to recognize the threats to EMS professionals of all sorts.  There are several organizations, most notably the Code Green Campaign, who’ve done an excellent job at suicide prevention and mental health awareness in EMS. Other EMS providers have noted the upswing in violence toward EMS responders and have raised awareness and training to address this threat.

However, one of the latest public safety suicides, that of a firefighter/paramedic in northern Virginia, really hit home to me. There are allegations that the medic in question was the victim of workplace bullying and cyber-bullying.

Somewhere, somehow along the way, the public safety world got fed a lie in that hazing and bullying are part of a so-called brotherhood. There’s certainly nothing wrong with some good natured teasing and some ribald jokes (of which I know quite a few).  However, when you’re continually targeting a particular person or group at your workplace, that’s definitely “not cool.”

I’ve been in some organizations, especially when I was younger, where jokes got carried too far.  When I was much younger, I was, for a short time, a midshipman at the U.S. Naval Academy.  I saw hazing.  I experienced hazing.  And all it did, at least in my case, was cause me to reevaluate my decision about a naval career.  There’s no brotherhood in tormenting those beneath you.  And “they did it to us” is no justification for continuing to do the wrong thing.

We’ve got way too many toxic workplaces in public safety.  The behaviors range from bullying to hazing to cliques that control the workplace.  I could spend an entire post on the destructiveness brought on by the cliques of “cool kids” in a workplace that serve to alienate and marginalize everyone else.  When you combine the “cool kid” clique with social media posts where the “cool kids” brag about their weekend exploits and hijinks, particularly with willing and participating members of management, you create a toxic culture where some members of the organization become ostracized.  Whether it’s intentional or just ignorant, it’s the height of hypocrisy to discuss teamwork and have teambuilding exercises when there’s alienation occurring right underneath ones’ eyes.

Between provider suicides, mental health crises, and losing EMS’s best and brightest to other professions, it’s clear that EMS has some issues to resolve.  Resolving those issues is going to require a massive shift in attitude towards how we treat other, towards a real brotherhood (or sisterhood), and making things at the station a hell of a lot less toxic.  It’s time to realize that being a professional is about doing the right thing, not just the fun thing — and it begins with how we treat each other. Let’s have that discussion about how we’re treating each other.  I’m not completely sure we’ll like what we’re hearing.

It Depends

Anyone who knows me in real life or has heard me talk about the law has heard me say that the lawyer’s favorite answer to any question is always, “It depends.”

In the law, we have a lot of sayings.  “Bad facts make for bad law.”  And another favorite question of mine is “What does the contract say?”  These sayings, among many other legal maxims, recognize that answers to most legal questions are nuanced and there are many variable factors in answering the question, including the facts underlying the matter and the law of the jurisdiction.

Yet when I switch roles from lawyer to paramedic, I never cease to be amazed by the number of EMS providers who want hard and fast answers to complex medical questions.  They want an “If A, then B” approach where their ability to make decisions is binary (yes/no), as opposed to providing for nuance and judgment.  The answer in almost every scenario facing a medical provider is incredibly dependent on many subjects, including provider skill, patient presentation, access to definitive (and appropriate) care, and availability of resources. In other words, what works in rural Nevada doesn’t necessarily apply in downtown Boston.  And one rightfully expects different measures to be taken based on patient presentation.  It’s really short-sighted and dare I say, ludicrous, to expect complex questions to be answered with simple linear yes/no answers.

Part of being a professional, in any field, including EMS, is that we embrace nuance and subtlety in our practice.  By embracing the fact that uncertainty and nuance enhance what we do, we become professionals.  By demanding a liner flowchart, we remain technicians.  And ultimately, it remains my core belief that EMS providers are, even in a limited way, engaged in the practice of medicine. Practice your profession.

Problems With EMS Research

Every now and then, we get the latest news about some “groundbreaking” study involving EMS or even tangentially connected to EMS.  The older I’ve gotten (and hopefully a bit wiser as well), I’ve come to take most of these studies with a grain of salt.  I present to you a couple of reasons why.

First, most of these academic studies are done where the academic medical institutions are — typically big urban areas with ready access to full-service teaching hospitals. When you have a five minute transport time to a facility where every specialty of medicine is present and each attending physician goes by “Professor,” there is something to be said for rapid transport being treatment.  That goes even more so when your large urban EMS system is comprised, in part, of providers who have little interest in the clinical practice of medicine.

Next, most EMS research seems to have almost a fetishistic focus on resuscitation.  I’d surmise that the reasons are twofold.  First, the research outcomes are easy.  Unlike The Princess Bride, there’s no mostly dead.  It’s either dead or not dead.  It makes for easy endpoints in research.  Second, since American EMS was initially based on accidental trauma and out of hospital cardiac arrest, the resuscitation interest seems logical.

As such, we have ended up with some of the research questioning the value of paramedic-level providers.  And it’s true to an extent.  A BLS provider is perfectly capable of transporting a traumatic injury to a trauma center for the one intervention that matters — surgery.  And in the majority of cardiac arrests, BLS interventions of chest compressions and defibrillation are what matters.  And doubly so in both instances if you live in a large urban area with a plethora of hospitals.

But here’s what little of the research addresses.   Firstly, suburban areas, much less rural or frontier areas, where transport to definitive care is not measured in single digits.  In some rural and frontier areas of my home state, the highest level of medical care available in the county after normal business hours is a paramedic.  In these cases, there’s undoubtedly a benefit to providing the advanced level of care that a paramedic brings — but because there’s no “science” to definitively support this assertion, there’s skepticism at best about providing advanced level care. Additionally, some paramedic level interventions defy easy measurement.  Unlike the outcome of cardiac arrest – dead or not dead – it’s a bit more challenging to quantify and measure symptom relief. “Sir, earlier you described your ingrown toenail pain as 12 out of 10. Now that you’ve had some pain relief, what’s the pain level now?”  Meanwhile, the femur fracture patient says they are fine and don’t need pain management.   Similar measurement difficulties can occur with other medical crises such as respiratory distress and chest pain.   It’s hard to quantify subjective measurements.

What would go a long way toward providing meaningful EMS research for the rest of EMS would be to develop some research consortiums and studies that occur outside large urban medical care systems.  Factoring in the distance to transport to definitive care and removing the maniacal fascination with cardiac arrest resuscitation would be a huge step in providing meaningful data to EMS providers in suburban, rural, and frontier EMS systems.  One thing we know about EMS is that one system solution doesn’t fit all.  It’s time that our research agendas reflect that reality as well.

“Go to the ER or call 911”

I’m getting up there in years.  Maybe not as old as some of my friends and mentors, but I’m getting there.  I don’t necessarily look back on the past as the “good ol’ days,” but I do recognize that things have changed — including medicine.  At the most fundamental level, our American system of healthcare, based largely on third party payment of insurance claims, has changed as well.

Years ago, if you got sick, you’d call your general practitioner and he’d make a house call.  As Medicare and Medicaid changed the reimbursement model (and private insurance adopted many of these standards), the house call became antiquated, so your doctor would meet you at their office, even after hours, to deal with an urgent matter.  As this model changed — and emergency medicine advanced — your doctor would meet you at the hospital ER.  Now, if you call your doctor after hours, you’re most likely to hear a recorded statement that says, “If this is an emergency, hang up and call 911 or go to the nearest emergency room.”

The result of this is that emergency rooms are crowded and EMS call volume continues to climb. The response from the emergency medicine world isn’t exactly inspiring.  Numerous individual EMS providers bemoan “911 abuse” for matters that aren’t “real emergencies.”  And now a noted emergency medicine physician-blogger has opined on “the go to the ER mentality of American medicine.”

Economics says that people are fundamentally rational. So, let’s take that approach.  If you have a medical problem and “do what you’re supposed to do,” you call your primary care physician.  With any luck, you’ll be able to get an appointment for an office visit in the next few days. If the matter is VERY simple and resolves quickly, you’re just out the copay for an office visit, assuming you have insurance.  If the matter is beyond the ability of what “evidence-based medicine guidelines” (AKA protocols for primary care medicine) allow for a primary care physician, you can expect multiple follow-up visits, referrals to specialists, and referrals out for lab work and imaging, all with their own separate copays and co-insurance.  Meanwhile, you’ve also lost time from work and your regular life as well because all of these visits have to happen between 8 AM and 5 PM on weekdays. Tell me how agreeing to “play by the rules” of American medicine is rational?

However, if you go to an emergency room, you’ll be seen by a physician trained in emergency medicine, which covers a wide spectrum of medical care.  You’ll also have access to lab studies, imaging, and, if warranted, consultation with specialists.  While the copay and coinsurance will be significantly higher, you are paying for access to a one-stop solution — and one that doesn’t require an appointment and is available 24/7. And if you call 911, you get a literal house call from a group of trained mid-level providers who show up with diagnostic equipment and medications that most primary care physicians don’t have in their offices — along with a ride to the above referenced emergency room where the majority of your medical needs can begin to be addressed.

Is emergency medicine, both in-hospital and prehospital, over utilized?  Absolutely?  What’s the solution?  I honestly don’t know.  I do know what doesn’t work — and that’s emergency medicine providers complaining about overutilization of emergency services.  In all likelihood, there’s probably no one solution. From the standpoint of business and economics, I’ve never known a successful business model based on telling people they don’t need your services and turning them away. Emergency medicine, both EMS and emergency departments, need to embrace their role as providers of unscheduled medicine to the masses.  Likewise, primary care, in order to remain relevant, needs to understand that not every patient’s needs can be scheduled two weeks from next Thursday and only during regular office hours. The problem is not an unequal or even inefficient model of healthcare delivery.  The problem is and remains a healthcare delivery system that is not meeting the schedule and demands of modern society.

Online EMS Learning

EMS social media, whether it’s a blog, podcast, or even a Facebook page, has greatly improved and democratized the access to advanced knowledge in EMS.  The ability to hear about and learn from renowned clinicians and educators and to become rapidly informed on cutting edge research cannot help but improve the average EMS provider’s knowledge base and clinical abilities.

Having sung the praises of EMS social media, I’d share a few warnings, though.

There are a lot of people NOT to learn from.  Namely, there are the pedants out there who know the minutiae of medicine.  These people rarely put things into proper perspective.  For the newer or less confident provider, the only thing they offer is self-doubt and a loss of confidence. We all have to walk before we can run and the social media pedants often forget that.  A newer EMS provider may well not know subtle EKG changes or the minute details of pharmacodynamics of a medication.  Overwhelming them with information may cause the newer provider to run away and retreat into a mindset where they believe themselves to be an inadequate provider as opposed to a provider who’s not necessarily been exposed to the concept(s) in question. The EMS pedants rarely account for the experience level of the provider or the relevance of the information to EMS practice.  Rather, everyone who doesn’t master knowledge to the level of the EMS pedant is dangerous, incompetent, and quite possibly doesn’t even like kittens, puppies, and pizza.

You’re going to make mistakes.  The truth is that in medicine, unlike the social sciences, there are answers that are wrong.  It’s ok to make mistakes.  The critical step is to learn from the mistake.  Some of us on EMS social media, including me, engage in Socratic dialogues designed to educate and help you learn the fallacies and errors of your position. It’s rarely personal, but rather a way to educate.

On a similar note, expertise IS often a substitute for experience.  Someone who’s a physician is going to have a much better understanding of medicine than a new EMT.  Likewise, someone who’s an attorney with prehospital medical experience is likely to have a deeper understanding of the law than someone whose legal education consisted of having a PowerPoint presentation read to them.  Just like there are wrong answers, there are also people whose expertise and education give them more credence.

In medicine, as in the rest of the professions, there are few absolutes. And the more education one acquires, the less definite the answers become.  The absolute rules hammered during a 180 hour EMT course become increasingly nuanced with more education and experience. I’ve always said that, in law, the answer is “it depends,” primarily because of the facts of a case and the laws of the relevant jurisdiction.  In emergency medicine, “it depends” is often true — unless you’re an entry-level student or provider who hasn’t acquired the education or experience to appreciate nuance.  In those cases, the answers are always absolute and based on dogma.

So, my advice?  Get involved in EMS social media.  Get messy.  Make mistakes.  Engage in the dialogue. As the saying goes, good judgment comes from experience.  And experience comes from making bad judgment calls. For me, I know I’ve made countless friends, acquired a few mentors, and learned lots.  I hope it’s the same for you as well.

What We Really Are

I see a lot of people in EMS who want to be heroes.  I see a lot of people in EMS who consider us part of the public safety family.  Occasionally, there’s some heroism in EMS.  And yes, in many places, EMTs and paramedics are part of the public safety team. I also hear the term life-saving bounced around.  I can count on one hand the number of EMS calls where a life was immediately saved by EMS interventions.  Lives prolonged?  Yes.  Lives made better? Yes.  Lives saved immediately?  It’s a rare occasion.

I have a real concern, though.  None of those reflect the day-to-day reality of EMS.  In my opinion, after a few years in this field in a variety of settings, we rarely get to be heroes.  In fact, if we’re at the point of heroism, something’s likely to have gone really wrong in the course of the call. What we really do is deliver unscheduled out-of-hospital medicine.  Our definition of “emergency” often varies from the patient’s definition, but the God’s honest truth is that we’re here for our patients.  Period.

Over the last couple of days, I’ve been pretty dismayed by some posts I’ve seen in EMS social media groups, whether by new EMS students or experienced providers.  I’ve seen posts advocating “punitive medicine” like ammonia caps and dropping the patient’s hand on their face to determine if the patient is “faking” a seizure.  I’ve seen other posts asking how to identify “drug seeking” patients so that a provider can hold back pain relief.  I’ve seen posts advocating that EMS providers be allowed to decide who gets to go to the emergency department. And I’ve seen posts by supposedly experienced paramedics advocating “just taking the patient to the hospital” rather than performing a complete assessment and providing treatment all because the hospital is close.

I get all of these complaints.  I really do.  We’ve all been on the shift where the calls keep coming and it seems like no one really has a supposedly legitimate emergency.  I’ve complained.  I’ve griped to my colleagues. And I try not to let it impact what I’m doing as a medic.

The reality is that we may be public safety heroes who save lives — occasionally.  But what we truly always are is professional caregivers.  Part of the obligation that you have is to suspend your judgment of the patient in order to CARE for them.  Even the most malevolent, challenging psychiatric “frequent flyer” has issues that we’re not going to be able to understand, much less fix as EMS providers.  Our duty is to assess the patient, provide care as we’re educated to, and get them to an appropriate destination to address their concerns.  When we start embracing the care aspect of the job more, we’re going to have less burnout, better outcomes, and probably some happier EMS professionals.  Until that point occurs, I’m concerned — because I’m seeing what people think is acceptable.  Ask yourself if that’s how you’d want your family treated or if you’d be proud for the local news media to showcase your last call.

It’s time for all of us in EMS to take a look in the mirror and see what we’re becoming.  I, for one, am not sure that this what any of us should accept or condone.  We can do better.  I know because I’ve seen us do better.

At the very least.

I was talking with a local college EMS faculty member about determining the right hospital choice for the right patients.  She rightly pointed out that emergency physicians routinely deal with patients who are brought to the hospital by themselves, family, or friends.

Here’s my premise about what we do as EMS professionals, especially as it relates to taking the right patient to the right hospitals for the right conditions:  We need to be doing a better job for our patients than transport via private vehicle.

Whether it’s assessment, destination determination, treatment, patient advocacy, or patient comfort, our goal needs to be that we’ve done a better job, each and every time, than the patient would have from getting a ride from family or a friend.

It’s arguably a low standard, but I’d argue that we aren’t hitting that standard all of the time.  And until we do, it’s hard to justify the existence of EMS. Whether it’s the bean counters who balk at the price, the “policy experts” who balk at the outcomes, or the customer satisfaction gurus who do the patient surveys, EMS is doomed until we can prove, consistently, that patients do better with EMS than without.

Why is learning bad?

I’ve been blogging a bit more lately and engaging myself a bit more in the EMS world, both locally and in social media. One continuing theme I notice in EMS is that there’s a sizable number of EMS providers who actively discount and discourage education.

Whether it’s derisive comments about being “book smart” versus “street smart,” comments discounting the importance of an entry level exam to determine a safe level of minimal competency, or the constant demands to water down the curriculum because we “don’t need to know it,” the reality is that the rampant anti-intellectualism in EMS holds us back from professional development, respect, and ultimately a sustainable career path as a prehospital professional. Additionally, our rampant discounting of knowledge and education means that we’ve placed the EMS profession at the mercy of others to determine our destiny.  Bluntly, look at the number of non-EMS types on almost any committee discussing EMS, whether regulations, education, or practice.  You’ll never see that ratio of non-professionals in any other health care profession. The solution is simple.  Our profession has to embrace both the academic pursuit of prehospital care and developing a professional identity (and knowledge base) of what EMS is.

The extreme focus on skills to the detriment of a core foundation of knowledge dooms EMS to being, at best, a skilled trade.  There’s nothing wrong with a skilled trade.  I know plumbers and air conditioning techs who make more than many attorneys I know.  But I also know that there aren’t skilled trades in healthcare.  EMS has to have a professional identity, which begins with a core set of knowledge.

When we embrace that there is a core set of intellectual knowledge to be an EMS professional, we will find that we control our destiny as a profession. Whether the future in EMS is community paramedicine, critical care, tactical casualty care, or even something we haven’t yet identified, EMS can’t grow or move forward until we realize, recognize, and embrace that there have to be minimal standards to entry into the profession and that there’s a core base of knowledge in EMS, which should ideally be developed and guarded by EMS professionals. Until then, we’re just complaining about the test being too hard, wondering why the average EMT could make as much money at McDonald’s, and wondering why so many good medics leave EMS for another field.

No matter how you look at it.

No matter how you look at it, no matter how you say otherwise, the reality is that emergency medical services, whether at the basic life support level or the advanced life support level is, plain and simple, the practice of medicine.

Those of us with a passion for EMS, myself included, regularly dream of what EMS can (and should) be and bemoan our current state.  Things I regularly despair over include the lack of professional development, professional identity, and pursuit of excellence.  You know, many of the same traits that other health care professions do a much better job of than EMS does.

Sadly, in my mind, the reason that EMS continues to lag behind the rest of the healthcare professions is that we’ve made it too easy to become an EMS provider. The reality is that most health care education programs are degree based and have college entrance requirements at a minimum. EMS – not so much.  We all know how hard it is to get into medical school or even nursing school.  EMS seems to be the exact opposite.  The entrance exam for most EMT programs is a check that clears the bank.  The entrance requirements for many paramedic programs are not much more stringent.  But that’s to be expected, we define EMT and paramedic by a set of skills rather than a core foundation of knowledge.

So, should it really surprise us that we haven’t progressed any further yet?  We’re allowing people who are unprepared for postsecondary education to practice medicine, albeit with a limited scope. To me, it’s little wonder that dogma, anti-intellectualism, and the “meet minimal standards” mindsets pervade so many EMS systems.  It’s little wonder that in many (note that I didn’t say all) fire-based EMS systems, the EMS side of the operation is seen as punishment or an assignment to be escaped from eventually.

Heck, to me, the real wonder is why some of us continue to engage in the quixotic pursuit of making EMS a respectable, recognized practice of medicine.