Some random observations on what we do

I was having a discussion with one of my favorite younger medics.  He’s brilliant; he’s got a mastery of the science; he’s just convinced he’s right and won’t always let you forget it.  (Sound like anyone you know?)

We reached a couple of brilliant conclusions.

  1. With the current state of EMS education in anatomy, physiology, and pharmacology, I think it’s eminently reasonable to expect entry level medics to have mastery of the bare minimums of knowledge, particularly relating to medications and expand and grown their knowledge base through continuing education.  Of course, this means that continuing education becomes just that, rather than a biennial repeat of topics you already knew about.
  2. EMS won’t be fixed with one big solution. It’s going to be fixed one medic at a time.  In other words, if you aren’t mentoring or being mentored by a colleague, why not?
  3. Two of the most underrecognized failings of the average EMS provider are that we don’t understand the long term effects of our therapies nor do we ensure that the right patients get to the right hospitals.


The Five Most Dangerous Words In EMS

There are a lot of phrases that encapsulate the “meets minimum standards” mentality that continues to hold back EMS.  However, one phrase continues to exemplify why EMS is relegated to being considered “unlicensed assistive staff.”

That phrase is : “Don’t need to know it.” This phrase captures the anti-intellectual bias that exists in EMS. (For example, “You don’t need book learning, let me teach you how we do it on the streets.”)  This phrases captures the blind faith in dogma, whether spread by their instructors, their colleagues, the National Registry, or what someone who thinks they heard about a legal case from two states over…

As we engage in fitful efforts to embrace mobile healthcare, particularly in dealing with long term chronic care patients, we’re going to find that our education is massively lacking in virtually any topic other than those topics tailored for a select few acute/critically ill and patients.  Paramedics have less clock hours in the classroom than most beauticians.  EMT programs are usually less than a quarter of the length of paramedic programs.

If anything, EMS should be pounding on the doors of educators asking for MORE knowledge and becoming life-long learners.  But instead, the sheep of EMS continue to bleat “Don’t need to know it.”

And now you know my skepticism when people claim that a new, improved EMS paradigm is just around the corner.  But I’m enough of an idealistic to keep tilting at that windmill.

Revisiting Paragods

A regular theme in the social media EMS world is the use of the word “paragod.”  With that in mind, I present you my thoughts that I recently shared in an EMS education group.

You are responsible for your own education, learning, and mastery of medicine. Bandying about the term Paragod when you think someone is smarter than you shows an incredible lack of maturity and a lack of acceptance of professional responsibility. We’ve been entrusted to care for the sick, injured, weak, and vulnerable. To me, that means that the obligation to care for them is above your sense of self-esteem. Rest assured that there is always someone smarter than you in this field and if you choose not to be challenged by new knowledge, you’re part of the problem in EMS.

In other words, I embrace the term Paragod.  I am responsible for my own learning. I am a guardian of our profession. I will help you reach your goals. But I am not going to do your work for you or hand you the knowledge.  The reasons are simple.  One of these days, you could be my partner or you could be caring for one of my loved ones.

Part of EMS developing a professional identity means that we maintain standards for our profession.  Just not like not everyone gets to be an astronaut when they grow up, not everyone can or should be a paramedic or EMT.  If that makes me a Paragod, then call me a Paragod.  I’ll wear the title with pride.

Challenges to Mobile Healthcare

As is the case in EMS every so often, we’ve attached ourselves to the supposed “next big thing” that will ensure adequate EMS funding, give EMS a level of professional respect, and provide for cleaner, minty-fresh breath.  As of late, that latest panacea is “community paramedicine” or “mobile integrated healthcare.”

Before I inject the lawyer’s skepticism, let me say that I wholeheartedly support an expanded role for EMS professionals in the world of healthcare.  I believe that EMS professionals are vastly underutilized in the healthcare field.  Personally, I believe that a variety of clinical settings would benefit from EMS providers being on site as a “rapid intevention team” to respond topatients who are acutely ill and/or rapidly decompensating.  Our ability to think under pressure, independently, would go a long ways towards improving patient outcomes.

However, let me throw out a couple of concerns with how/why “mobile integrated healthcare” may not yet be the solution that fixes EMS’s perceived woes.

  1. Who’s going to pay for this?  Right now, there are a lot of pilot programs being funded from a variety of sources.  Eventually, this funding is going to dry up and/or the funding is going to have to continue past a trial/pilot period.
  2. EMS providers are pretty darned good at reacting to acute events.  Many EMS providers don’t yet have the education in patient assessment, pathophysiology, and pharmacology to be effective in a longer-term setting.
  3. Attitude.  Sadly, look at the number of EMS providers out there who want to limit themselves to a minimal standards mindset and who don’t even see themselves as healthcare professionals.  Thrse are the same ones who recite the shopworn mantras like “diesel bolus” and “we can’t diagnose.”  “You call, we haul” is their mentality.

So, what will fix EMS and give us a place at the adult table in healthcare? I thought you’d never ask me.

  1. EMS needs to be reimbursed/paid for the care/interventions we provide, not solely as a glorified medical taxi with reimbursement for transport.
  2. We need to develop an identity of who we are and what we do.  Further, we need to ensure that, like any other regulated profession, we do not let others intrude into our professional, regulated space.
  3. Let’s embrace what EMS excels at — namely, using a public safety framework to deliver unscheduled, acute or urgent care medicine.

How can we achieve this?  We have to do the one thing that nursing beats EMS in every day — advocacy.  We need to be at the state capitol and in the halls of the regulatory agencies advocating for the future of EMS, rather than having various “stakeholders” define who they want EMS to be.  A professional identity would go a long ways towards making EMS a respected healthcare field.  The problem is that we aren’t educating the public and we aren’t making our presence known at the state house or at the myriad of regulatory agencies with oversight of what EMS does.

Of course, none of this is easy.  It’s a lot easier to look for the “next big thing” or maybe find a new t-shirt slogan.

System abuse? Not really.

A continuing recurring theme in EMS social media and in EMS in general is that we believe there’s a such thing as “EMS system abuse.” Usually, this manifests itself with some meme or catchy saying that 911, EMS, and/or the emergency room are reserved for “true emergencies.” Allow me to just say one thing – WRONG.

Let’s take it piece by piece. First, even for non-profit or government organizations, medicine is a business. Businesses exist to make money. When’s the last time you saw McDonald’s or a law firm tell you not to use their services? Does a lawyer tell you that your routine, uncomplicated will could be done with will-writing software? No lawyer would do that and remain in business. What makes emergency medicine so different? Why do we feel it’s in our best interest to turn away patients? And let’s face it – patients are another name for customers.

Next, imagine the worst EMS provider you work with. Would you trust them to be the “gatekeeper” that decides whether your family gets EMS treatment or whether that EMS provider gets to go back to his station and return to his Xbox? Take an average EMS provider instead. How many of us know enough medicine, pharmacology, pathophysiology, and assessment to make a good, informed decision about sick or not sick? While my blog isn’t meant to be a journal review, the current evidence shows that the majority of EMS providers don’t have the clinical sophistication, knowledge base, or good judgment to make the right call as to not transporting (or transporting to alternate destinations). As an attorney and medic, I can tell you the risk of allowing the average EMS provider to function as a gatekeeper to emergency care is too great. Yes, there are clear-cut cases of abuse of 911, but the temporary satisfaction that an EMT or paramedic gets from refusing to transport one specific patient is not going to address the underlying pathological issues that patient is dealing with – and the best place, under ourcurrent model of emergency care, to begin that process is the emergency room.

In my opinion, what we are really dealing with is the failure of modern medicine to meet the needs of a modern society that functions 24/7. I recently had a medical issue that took several office visits to my physician’s group practice, ranging from urgent care, to my primary care physician, and multiple specialists. Each of these visits (save the urgent care visit) took me away from my work and had multiple co-payments. Factor in the cost and convenience factors, especially with referrals and imaging, and it’s hard to say that I’m actually the intelligent user of medical care. Meanwhile, someone goes to an emergency department, and even if they wait, there’s access to an exam, lab work, at least some imaging, and the ability to consult/refer to a specialist.

The so-called “abuse” of emergency care may be a problem. Belittling those who use our services is 1) not the way we should treat our fellow man; 2) financially counterproductive; and 3) clearly not working. Maybe it’s time to adjust our medical care to account for after-hours availability and the need to meet unexpected/unscheduled healthcare problems.

Until then, it’s my personal belief that if your office phone number is 911 and/or the sign says “Emergency” on your workplace, then you’re first and foremost in the problem solving business. Let’s solve the problem of availability and access to quality care. We can do this – and do it without belittling those we see as beneath our expertise as emergency clinicians.

In Case You Missed It….

I’m now on EMS1 as well.   Talking about compassion.  Shocking for a lawyer!

Medical Practice By Cliche

One of my biggest complaints in EMS education and practice is that too many providers take clichés from t-shirts and turn them into the dogma of EMS practice.

Two of these overused sayings are similar.  “BLS before ALS” and “EMTs save paramedics.”  And they’re two sayings that when the President appoints me “EMS Czar,” I will ban with the severe penalty of taking away your collection of EMS t-shirts and Galls’ catalogs.

My biggest concern is that many of the people who repeat these saying the loudest (because we all know that in EMS, loud=winning) are those who are BLS providers who don’t have ALS education.  This is the equivalent of me spouting off that paramedics save physicians, even though I only have a vague idea of what happens in medical school or graduate medical education.

The realities are this.  These cliche sayings are nothing more than feel-good t-shirt sayings designed to boost the ego of entry-level EMS providers.  Furthermore, even a marginally competent paramedic doesn’t differentiate between BLS and ALS skills and assessment.  They synthesize the knowledge they have along with their experience to create a holistic view of the patient and treat the patient as such.  In the actual world, many patients, especially those with medical complaints require the assessment of a paramedic level provider, if not paramedic level interventions.

I fully acknowledge that there are some excellent EMT-level providers out there who are the exception to my semi-rant.  These EMTs are primarily found in EMS systems where there’s an extensive field training and continuing education process that mandates a level of independent BLS practice.  In other words, becoming a truly independent BLS provider ready to assume responsibility for patient care requires much more than what currently counts for initial EMT education.

But the sad reality in much of the EMS universe is that EMT education consists of little more than showing prepackaged PowerPoints, war stories, and some level of minimal competency.  With that current paradigm, there’s only a small subset of patients who would benefit from BLS treatment without at least an assessment from a paramedic level assessment.

Ultimately, like much of medicine, and for EMS in particular, you don’t know what you don’t know.  If you want to be trusted, the best recommendation I can give is to never be satisfied with minimal competence in the entry level of emergency medicine.  Quit worrying about justifying what is really an entry level skill set — learn and grow to advance your knowledge, whether formally through a paramedic certification, or at least through formal and informal continuing education.

As most of y’all know, I tend towards blunt.  Medicine is about helping people.  And you can’t help many people, including your partner, if you merely meet minimum standards in the minimum level of certification to staff an ambulance.  And this truth remains plainly evident no matter how much you cite cliches and stories that your instructor told you.

Reality is — we’re a team.  We all have a role to play and much of the role of the BLS provider is to assist the ALS provider.

If We’re Truly Doing Everything Doctors Do, But At 80 Miles An Hour

Look around the EMS social media world for any period of time and you’ll see a bunch of worn-out clichés.  One of the more popular ones is “We do everything a doctor does, but at 80 miles an hour.”

Ok.  I’ll accept your cliché.  And being a betting type, I’ll raise you one.  Let’s assume and accept that we, as EMS providers, are practicing medicine — because we are.  And we’re even diagnosing patients.  (Let that one sink in for a moment.  I’ll wait.)

Ok, you’re back.  So, yes, we’ve accepted the position that EMS providers are practicing medicine.  That means we’re getting a medical education as well, right?  And said medical education, regardless of how and where it’s delivered, should be at a level above high school, shouldn’t it?

You’re darned right it should be.  As I’ve mentioned in the past, for the paramedic provider, we’re trying to condense the critical parts of a bachelor’s degree, medical school, and an emergency medicine residency into, at best, a two year program.  That means there’s a lot of knowledge coming at students quickly.

Yet, of all of the education programs out there, EMS education seems to operate on the open enrollment model.  Did your check clear?  You too can try to become an EMT or a paramedic.

When we accept students who can’t express themselves in the English language, do simple mathematics, or have a rudimentary knowledge of the basic sciences of biology and chemistry, it should be little surprise that the course completion rates and National Registry exam passage rates are abysmal.  It should be little surprise that EMS students are constantly posting questions about examination and certification processes that could be discovered with a simple Google search. And it should be even less of a surprise that EMS doesn’t receive the recognition and respect that other allied health professions earn.

If we want EMS to be treated as a profession, maybe it’s time to enforce some entrance requirements.  Not everyone gets to be an astronaut or a starting NFL quarterback.  Maybe, just maybe, it’s time to say that you don’t get to play doctor in the back of an ambulance unless you have some minimum academic credentials.

We make a difference.

Everyone hears the propaganda about how EMS makes a difference.  Some of it might even be true.  I’ve had a few calls in my career where I’m at least somewhat convinced that having trained EMS providers on scene made some difference for the patient.  A couple of heart attacks, a couple of allergic reactions, and a couple of difficulty breathings remind me of how my partners and I might have saved a life.  Countless hands held, pain meds given, and nausea meds administered remind me of how the “little things” might make more of a difference than management in the administrative offices ever will be able to quantify.

But that’s not the difference I made today.  Today, I made a difference for two of my colleagues.  Between my presence on some EMS Facebook groups and this blog, people know who I am and what I stand for.  Even more importantly, because of the nature of social media, people know who I consider my EMS family.   One colleague, a younger EMT, came to me today and asked me the age-old question about their readiness to advance to paramedic.  We had a good conversation and a few laughs and I hope that at the end, I was some help.  Shortly after that, a paramedic colleague called me with questions about recertifying.

Neither of these calls were a big deal in the grand scheme of things.  But if we, those of us who consider ourselves to be “good” providers, motivated by the right things in emergency medicine, don’t make ourselves available as mentors, resources, or peer support providers, then someone else surely will.   These may be the the Low Information Voters who chant the shopworn phrases of low EMS standards.

So, for those of you who consider yourself to be good medics, you’re not truly a good medic until you’re helping someone else grow and advance.  The only way to grow the numbers of “good” medics is to not give an inch of ground to the “meets minimum standards” team.  And that means making yourself available and approachable to your EMS friends, family, and colleagues.

It’s that important.  Really.

And I couldn’t let this go without thanking a few unnamed physicians, a few people on the old Yahoo Groups, some Austin/Travis County EMS paramedics, and the family I grew into at Harris County ESD-1.  Each of y’all saw something in me, even when I didn’t.  Each mentoring opportunity I have is but a small attempt to pay each of you back.

Think Nationally. Act Locally.

There are a lot of new ideas floating around EMS these days.  Compact licensure for EMTs and paramedics just like nurses already have.  Community paramedicine.  New educational standards.  And the list goes on.

Here’s why many of these well-intentioned ideas remain just that — well-intentioned ideas.  Many well-intentioned EMS opinion leaders with well-intentioned ideas have no idea how, or more importantly, where a well-intentioned EMS idea makes into law.

With a few notable exceptions (EMTALA, HIPAA, and CLIA coming to mind immediately), most EMS laws and regulations are creatures of state government.  Overall, emergency medical services are provided at the local level and are regulated by state statutes and administrative rules/regulations.

I see a lot of EMS folks wanting either Congress or some national body (e.g. National Association of State EMS Officials, the National Association of EMTs, or the National Registry of EMTs) to DO SOMETHING, DAMMIT!   I don’t always oppose their ideas (well, except for my healthy dose of skepticism about the so-called “Field EMS Bill.”), but they’re usually barking up the wrong tree.   If you want to make changes to the regulatory framework of EMS, you need to quit looking toward Washington.

As a valued service to my minions and other readers, I’ll tell you the way to fix EMS.  First, learn where your state’s EMS laws are located in statute.  Second, learn where the state administrative regulations regarding EMS can be found and which state agency or agencies create, implement, and enforce these regulations.  Next, learn who your state representative and senator are.  Also, learn who are the senior management in your state’s EMS regulatory entities.  And learn who are the chairs of the legislative committees overseeing EMS laws.

And then, when you want to change how we do EMS, contact those people.  Write, call, email, or better yet see them.  While the results may not be as sexy as going to Washington DC in a hotel doorman’s uniform and getting pictures posted online, the results will be more effective, easier, and might just improve EMS. One state at a time.