Musings from the warped, cynical mind of an ambulance chaser and ambulance driver
Every EMS system thinks their model is the ideal model. And the truth is that it may be — for their locale.
However, the truth is not every model of EMS delivery can transfer to everywhere else.
In other words, Reno is different from Seattle which is vastly different from New Orleans. Anyone selling a one system fits all model is either a consultant, a charlatan, a fool, or any combination of those three.
If you listen to the folks from Boston, Seattle, and, to a lesser extent, Austin, you’ll hear that the secret to good paramedics is to have a small core of paramedics backed up by a larger group of EMTs. The theory is that the paramedics will be at the top of their game as they are reserved for those patients who truly require advanced life support care. In these systems, one promotes into the paramedic position, usually after working several years as an EMT, regardless of the certification level they were hired at. (In other words, in these jurisdictions, you can be a state-certified paramedic, but working only as an EMT.)
Minions, allow me to call BS on this. First, how does working as an EMT for a few years make you a better paramedic? Second, what’s an advanced life support call? I’d be almost willing to bet you that a fractured extremity isn’t considered an ALS call. Want to bet that the patient with a fracture would like a paramedic on scene. If that patient wants pain medications, there’s going to have to be a paramedic there. And yes, while I definitely buy the argument that too many paramedics lead to skills dilution, the skills that a paramedic truly needs, in other words assessment and critical thinking, come in on every call. As for intubation, chest decompression, and other “sexy” skills, they can be compensated for through skills labs and hospital rotations.
If we’re really worried about wanting to produce good, experienced medics, I’ll throw out two suggestions. First, have a good hiring process and a good salary and working environment. That will go a long way towards ensuring that your applicant pool consists of good, experienced paramedics. As for the inexperienced providers who have the potential to become good paramedics, hire them and put them through an extended internship where they work as a third crew member with experienced providers. Give them the opportunity to learn and practice while still having the safety net of experienced providers with them. I had an opportunity to ride as a volunteer medic for several years with Harris County ESD-1 (later Harris County Emergency Corps) as a third crew member, which gave me a ton of experience and confidence dealing with some very sick patients. That time at HCESD-1 and HCEC made me the paramedic I am today. (I can supply the names of partners to blame if you’d like…)
I realize that my experience as a volunteer third medic isn’t the same, but I definitely believe that offering an extended paramedic internship would be an improvement over requiring an arbitrary amount of time spent as a paramedic functioning in an EMT capacity. That model is nothing but a system wide application of the shopworn cliche of “BLS before ALS.” It’s time that emergency medical services approaches career development through an internship paradigm rather than through a “pay your dues” mentality.
Happy Friday, y’all!
A lot of my friends in EMS complain about fire-based EMS. I’ve been among them, although I think the problem with many of the large urban fire-based EMS systems is that they’re large. Once a service becomes too big, it’s hard to manage effectively and even harder to prevent a “lowest common denominator” practice of medicine.
The one thing I’ll give the fire service is that, even when they bitch about being on the ambulance, they indoctrinate a love of the job. And that’s not something you always see in the non-fire-based EMS world. Where is the EMS version of Alan Brunacini teaching customer service or our version of Rick Lasky teaching “Pride and Ownership?” EMS will begin to improve when people who love being paramedics are running EMS systems.
And if you don’t love being a paramedic (or EMT), there are plenty of ways to deal with the burnout, whether it’s a change of employer, more education, or finding an alternative practice setting. (You know, there are non-ambulance settings where you can be an EMT or paramedic.) But until we fill EMS with people who WANT to be in EMS and who understand that clinical excellence and customer service/problem solving skills are both critical, we’re still going to be the ambulance drivers.
Here’s another crazy idea for EMS. I’ve heard it from several people in the past and I think I could get behind it. What do y’all think?
Let’s separate the emergency response side of EMS from the pure interfacility transport realm. Emergency calls and emergent responses to healthcare facilities (e.g. nursing homes and physician’s offices calling for a patient to be taken to the emergency department of a hospital) would continue to receive ambulances staffed by emergency medical technicians and paramedics. Non-emergent interfacility transfers would receive a response from a transfer system. Transfer systems would be staffed by nurses’ aides and vocational nurses who have received extra training and an endorsement in patient movement, patient transport, and vehicle operations. As for the true “critical care” patients, the ones on multiple medications and/or ventilatory support, the minimum standard should be a true critical care paramedic. In other words, a paramedic with a true critical care background (and yes, I realize there are a ton of competing critical care certifications) and possibly backed up by nursing and/or respiratory care practitioners.
A while back, I blogged about owning what you excel at. EMS excels at providing emergent/acute care interventions on an unscheduled basis. In other words, 911 calls and emergency responses. Let’s focus on that.
I spent most of Saturday morning doing skills testing at Rice University in Houston for their Advanced EMT students. For those of you who don't know, Rice is a private university in Houston that routinely competes with the Ivy League. It also has its own student-run EMS first responder organization.
I was tasked with testing the students on the medical assessment skills station. I'll respect the NREMT process and rules and omit describing the scenario other than to say that it was a medical patient with the potential to "crash." You know -- the kind where you can use some clinical judgment on how to treat the patient.
Here's my problem. There were 48 possible points available to be awarded for completing the skills station. There's a point awarded for considering spinal immobilization. Points awarded two different times for checking AVPU. Points for each question in the SAMPLE and OPQRST mnemonics. But only ONE, YES ONE, f--king point for verbalizing a treatment plan and calling for appropriate interventions.
And I'd say that 90% of these very smart young people thought that the solution was to use the patient's prescribed medication and that alone. I think only 2 or 3 mentioned a couple of other medications that an Advanced EMT can use in this particular emergency. Yet all of them did mention high-flow oxygen via non-rebreather mask. Not one mentioned capnography. It was obvious to me that none of them understood the pathophysiology or pharmacology involved with this medical emergency.
EMS education and the National Registry process in particular have turned some of America's brightest youth into mindless automatons parroting the mantras of "BSI and scene safe."
The saddest part is that some of these young people may end up as physicians and medical directors. I will not be surprised when these aspiring doctors push a "monkey see, monkey do" set of protocols on their medics. What disgusted me is that NREMT doesn't even seem to care if you properly treat your patient or even know what you're assessing so long as you parrot BSI, scene safety, consider c-spine immobilization, and run down the OPQRST and SAMPLE
questions. Memorization counts and understanding is irrelevant.
None of these kids failed the skills station, but National Registry sure failed these kids and ultimately, their patients.
Having gone through this testing and evaluation process, I am now not surprised that the "best EMS service in Texas" walked my mother to the ambulance after trying to push a refusal on her.
Sorry, I'm just disgusted.
So many of us in EMS complain about “cookie-cutter” protocols. You know, the ones that mandate blindly following a flowchart instead of allowing you to use your clinical judgment and knowledge.
Why do we have cookie-cutter protocols and why are these policies rigidly enforced? Quite simply, your medical director and EMS service often write these protocols for the lowest common denominator. In other words, there’s a moron (or morons) who likely caused your medical director to write one of those clinical advisory memos. Or maybe the operations manager sent out an email about some bone-headed move that you didn’t even think was humanly possible.
When you see protocols mandating what equipment you have to bring into each call, it’s because “Whatshisname” didn’t take a cardiac monitor into a chest pain call. When you see that all patients have to be transported on a stretcher, it’s because “Whatshisname” walked a syncopal patient out to the ambulance. When you have to call a field supervisor before you can leave a refusal, it’s because “Whatshisname” told someone that their heart attack was indigestion. Each of these policies take away the clinical judgment of the average EMT or paramedic because someone proved that somehow, in some way, there’s a below average EMT or paramedic who isn’t worthy of complete trust.
“Whatshisname” harms each of us in EMS. Most patients (and thankfully, it truly is MOST of our patients) rarely call for an ambulance for a medical emergency. When we show up, we owe it to the public to make sure “Whatshisname” isn’t treating the public. Sadly, because so many of us in EMS tolerate “Whatshisname,” our management and medical direction have to mitigate for him/her by drafting policies and protocols that take away our ability to utilize our brains or common sense.
The solution is simple — we need to police our own profession. When you hear about a “Whatshisname,” speak up. Don’t saddle someone else with “Whatshisname” for a partner. Your patients and ultimately, our profession, will thank you for it. Until then, every patient goes on the stretcher, offer transport to every patient, get two sets of vital signs on every patient, and give the “unconscious, coma, or death” speech to every patient who wants to refuse transport. Why? Because “Whatshisname” is still out there.
Here’s the deal. A bachelor’s degree in EMS is highly unlikely, in and of itself, to produce a new breed of supermedics who are going to suddenly gain the immediate respect of physicians and nurses, become the newest level of mid-level healthcare professionals, and increase both reimbursements and EMS salaries. So, why push for a bachelor’s degree paramedic?
Here’s why. A college degree is, in our society, the commonly accepted indicator of academic achievement. Some might even argue that a degree is an indicator of intelligence. I’d disagree with that, having met a Harvard-educated lawyer who barely understands the law and knowing several borderline geniuses who never did finish college.
To me, a college degree proves maturity and commitment to reaching a goal. It shows dedication and in the case of attending a large state university, the ability to achieve your goals in spite of a gargantuan bureaucracy that often throws roadblocks along the way. (Try financial aid or registration back in the days before the web was around. Not fun at all, I tell ya.)
A bachelor’s degree in EMS will probably not cover any additional skills or interventions. Heck, it probably won’t even add that much theoretical knowledge of medicine. What it will add above and beyond a certificate or even an associate’s degree is a stronger foundation in general knowledge, written communication, and critical thinking. When you have to take English, some social sciences, science classes, and maybe even some fine arts, your world expands infinitely beyond merely memorizing a cookbook of treatment options.
If we’re serious about EMS 2.0, 3.0, or whatever reset we’re on this week, let’s swing for the fences. Paramedics should possess a bachelor’s degree to practice and the only people allowed into a “medic mill” or a certification program should be those who already have a bachelor’s degree.
When paramedicine is no longer merely a skill set and the majority of paramedics can turn out a report that doesn’t read like a junior high text message, we might be able to reach some of the other goals like higher pay and reimbursement models based on treatments, not transports.
Just the thoughts rattling through the mind of (possibly) the most overeducated volunteer paramedic out there.
So, I couldn’t resist commenting on one of the trolling Low Information Voter medic groups on Facebook. There was a discussion by some sort of EMT or first responder about automatically applying a non-rebreather mask to a patient with a stroke. This provider got upset for the paramedic removing the mask and called him/her a “paragod.” And since I couldn’t leave well enough alone, I commented. I probably should’ve lowered my snark factor, but that’s not a fault of mine. Rather, it’s a value added option.
So, what is a paragod? From best as I can tell from Central Texas (home of the world’s best BBQ), a paragod is a thoughtless term hurled by Low Information Voter/medics at those medics who they think are “too smart.”
Yep. I’m guilty. I’m educated outside of EMS. The liberal arts and legal education means I’m likely to use critical thinking. I make it a point to attend and participate in continuing education. Continuing education occurs in card course, in-house CE classes at the department, state and national conferences, and yes, online too. I knocked out my National Registry transition course and recertified six months early. I’m the one that a lot of my friends come to when they’re looking for an answer on continuing education. I keep up with the science, because medicine is a science. Science changes and so the medicine changes. Sadly, too many people in EMS (especially at the lower levels of certification) cling bitterly to that which was taught to them in their initial education program and blindly follow the protocol cookbook for the recipe to treat patients. EMS is changing, even (perhaps especially) at the BLS level. If you don’t know about passive oxygenation, CPAP, permissive hypotension, selective spinal motion restriction, pit crew CPR, or oxygen titration to avoid free radicals, you’re already behind the times.
So, here’s the deal. I’m going to continue being what you call a paragod. I’m going to be current on my medicine and the science behind it. You have two choices — evolve or become extinct. That’s science, too.
Until then, I remain your friendly neighborhood paragod. Arrogant? Honestly, no. I’m pretty approachable. I just seem arrogant to the willfully uneducated.
Time to stir up some controversy here.
If I was an EMS medical director (Yes, I know, scary thought in and of itself.), I would no longer require any resuscitation “card courses.” No more ACLS, CPR, or PALS. Why? Several reasons.
1) The “current” science behind the current ACLS/PALS/BLS-CPR standards is already dated. New science is regularly coming out about cardiac arrests. What about dual defibrillation? Therapeutic hypothermia initiated during the arrest? Nope, not in the current standards. Mechanical CPR devices? Barely mentioned Heck, the “pit crew” model of CPR which is rapidly becoming the de facto standard of care for EMS CPR isn’t even accepted by the AHA yet. If you think John McCain and Ted Cruz are conservative, the AHA’s resistance to new changes is legendary. Heck, it wasn’t even until this go-round of ACLS revisions that waveform capnography was added.
2) Between the AHA and JCAHO wanting/encouraging virtually every nurse, physician, and respiratory therapist to have a current ACLS card, the ACLS standards have become a laughing stock for those people who are actually expected to perform resuscitations. The “everyone gets a card” mentality means that the current courses have become another example of the “everyone gets a trophy” mentality that permeates our country right now.
3) And besides, for those of us in the EMS world, our local protocols are going to override a “canned” card course anyways. Thank goodness for that in most cases. I’d rather work a code the Austin/Travis County EMS, Wake County EMS, or Harris County Emergency Corps way than the already-dated, hospital-oriented “card course” way.
In fact, if I was a medical director, the only card courses I’d require would be Advanced Medical Life Support (AMLS) and PreHospital Trauma Life Support (PHTLS). Those are courses designed for EMS providers and based on assessment, not blind parroting of rote, already dated protocols. It’s time EMS progresses beyond rote memorization and embraces assessment-based interventions and sound science. Kudos to those EMS medical directors and EMS systems who’ve moved their protocols to accept the current science — and who don’t let the possession of a “card” define competency or currency in resuscitation science. I know for certain that Austin/Travis County EMS no longer requires BLS-CPR cards in recognition of their higher standards with “Pit Crew” CPR training. Similarly, Cypress Creek EMS (near Houston) no longer requires ACLS cards of their paramedics in recognition that some of their clinical standards exceed current AHA guidelines. Take the plunge — and free yourself from the tyranny of sitting through the same biennial DVD presentations. We’re EMS. Cardiac arrest is a huge chunk of why we were created in the first place. We’re supposed to OWN resuscitation. Let’s show it — by educating ourselves ABOVE the standard.
Thoughts, y’all?
Why are the fire service and law enforcement considered essential public services and EMS is rarely considered, if at all. Why do politicians and opinion leaders buy the “snake oil” from some private EMS operations about operating for little or no subsidy and not understand what they’re getting for that little money?
The answer is quite simple. It’s because no one knows what EMS does. And we have ourselves to blame. We’ve done a great job of handing out “Call 911” stickers. People have gotten the message to call 911 for EMS. The problem is that they don’t know who EMS is, much less what we do. With such a lack of public education, can we blame people when they call 911 for a prescription refill, but don’t call EMS when they’re having crushing substernal chest pain radiating to the jaw and down the left arm?
I have a variety of friends in a variety of professions. I’ve had to correct attorneys as to the difference between an EMT and a paramedic. I’ve had an ICU nurse ask me what IV antibiotics I stock on my ambulance. And tonight, a police lieutenant told me he had no idea what EMS did, but that he appreciated them dealing with intoxicated college students.
And how does EMS respond to this lack of knowledge? In most cases, the same ways we’ve always dealt with it. “Call 911” stickers, blood pressure checks during EMS Week, and then complain about the lack of respect that EMS gets even during EMS Week.
Folks, people still see us as barely educated ambulance drivers. It’s because we haven’t taught them anything. The fire service and law enforcement embrace the public education mission. EMS doesn’t. Plain and simple. The cops and the firefighters have “citizens’ academies” where they show off their organizations and answer questions. EMS claims we can’t because of HIPAA, lack of funding, or vague concerns about liability. We need to be showing off — opening the ambulance doors up for real tours — where we show what we can do, allowing ride-alongs, and reaching out to the media.
The people who we don’t educate about what EMS does and why a well-funded, clinically progressive EMS system makes a difference are the same people who are going to call 911 at 3 AM because they ran out of their Xanax. Perhaps even worse, the same people that we don’t educate about EMS are the volunteers that never joined or the community leaders that don’t support the next tax election or fundraising drive.
