The Paramedic Shortage

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

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

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

 

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

 

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

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

And So It Goes

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

 

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

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

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

And so it goes.  Indeed.

The Degree Advocates

After a few minutes engaging this morning on the American Paramedic Association Facebook page, I’ve realized that many of those advocating higher education and a degree requirement for paramedics have little understanding of higher education or how higher education works.

There’s tons of people saying they need more science classes and advocating for specific EMS related courses. Meanwhile, there’s a lot of people also advocating against any humanities or liberal arts core curriculum coursework. I would submit to you that a course in research design and methodology like you see in many bachelor’s level social science curricula may be of much more long term benefit to EMS than a specific, technical course in the most recent innovation. Remember when backboards and rotating tourniquets were considered current EMS practice? However, a course in understanding research would enable the paramedic to have a lifetime knowledge base in evaluating EMS innovations and a healthy dose of skepticism, which is a virtual requirement for scientists and clinicians.

Many of these people arguing for an EMS degree don’t understand that college is designed to produce a well rounded education, even if the degree is in a specific field. There’s several people saying that the EMS associates degree needs to be a technical degree. What they don’t understand is that an Associate of Applied Science degree is often a terminal degree for a technical job. (Think ITT Tech or DeVry for those of us that remember the commercials on daytime TV.) And further, an AAS degree often doesn’t easily transition to a BS or BA degree in the future, even further limiting EMS career progression and upward mobility.

Bluntly, the more I see, the more I think an AAS degree will end up dooming EMS to remain a technical education with limited chance for upward mobility or further education. What I’m seeing is largely people engaging in either playing pretend at creating their dream college curriculum or wanting to turn card course curriculum into college hours.

I’m almost willing to come on board with requiring a degree for paramedic providers. However, I think we need to aim for the ideal and negotiate to what’s manageable. In my opinion, I believe that the role of a paramedic is actually that of an advanced practitioner with the ability (and likely the requirement) to exercise critical thinking and clinical decision-making. That critical thinking comes with an expanded knowledge base including the core liberal arts curriculum. And that level of education happens at the bachelor’s degree level.

The political process, which is ultimately how we’ll reach a decision on what education is required to be a paramedic, requires that we negotiate from an ideal solution to get to a realistic solution. The ideal is a paramedic with a bachelor’s degree, whether that’s a bachelor’s degree in paramedicine or a bachelor’s degree in another field, followed by a paramedic transition curriculum (see also the plethora of BSN transition programs for those with a BA/BS degree).

If we end up making the paramedic degree requirement an associate of applied science as many seem to be advocating, we’re dooming EMS to remain a technical field with limited upward mobility. An EMS degree, especially for the paramedic level, should not be in the same category as HVAC technicians or diesel mechanics. (Truth is, the average HVAC technician or diesel mechanic probably has a better salary than the average EMS provider — or even many so-called “white collar” jobs.)

As I’ve said before, we’ve got one chance to get the degree requirement right. Let’s not foul this up. And if we turn this into an echo chamber among ourselves and creating a curriculum that’s solely based on “cool new skills” for paramedics, we’re dooming ourselves with a degree requirement that ends up producing perishable skills that will be outdated within a few years of practice.

Masters of Our Own Destiny

EMS is dependent on others to get what little we do.  Whether it’s getting physician involvement for clinical changes or convincing those with the money that a new ambulance is needed, we have to get others involved in our destiny.

If you listen to the current voices on EMS social media, you’ll hear the lamentations that EMS is broken.  The current consensus, promoted by all self-proclaimed EMS save those in the fire service, is that EMS degrees are what will surely fix EMS and make us respected.  Mind you, the EMS consensus has brought us some other sure-fire winners as system status management, declaring EMS an “essential service” (Hey, where did that go?), and community paramedicine.  We’re on EMS 3.0 or something now and we still haven’t mastered the basics of getting the right patients to the right hospital and treating people right, both as people and as patients.

I agree that more education is needed for EMS. But the last thing we need to do is follow the rest of the healthcare professions and have a solely clinically focused degree.

Too many people in EMS (and the rest of healthcare) think that all you have to understand is the medicine. If you don’t understand (or participate) in the policy and business aspects, others make those decisions for you. If you don’t believe me, look at our modern American healthcare system. For years, physicians refused to be involved in the business of medicine.  As a result, hospital and healthcare administrators developed to handle the business of medicine.  And ultimately, we have ended up where we are currently — where a lot of decisions about medical care are made by the business office rather than by those providing the actual care.

It often seems that there’s a belief in the world of healthcare that being involved in business or policy is somehow “unclean” or beneath the profession.  As a good friend of mine said, “Even if you aren’t interested in politics, politics is interested in you.”

So, in short, I’m not opposed to increasing EMS education.  But what an EMS degree should NOT be is a degree focused solely on the clinical practice of medicine.  Too many of the EMS degree advocates on social media would promote a degree that awards three hours of college credit for a course entitled “Latest Clinical Fads Capstone.”

EMS, like the rest of the healthcare world, does not exist solely in a clinical vacuum. For EMS to advance, we need to understand the business of healthcare.  That means an EMS degree needs to include coursework in the political and regulatory process, finance, personnel management, and the research process.

In other words, it needs to be a well rounded degree as opposed to a narrowly focused clinical pathway that will be doomed to irrelevance with every change in medical practice. But without this kind of education, an EMS degree is doomed to become an expensive addition to the current workplace.  If the current people pushing for a degree requirement better understood the non-clinical aspects of what we do, they’d see the potential pitfalls of an EMS degree such as a lack of buy-in from higher education and the availability of appropriately educated EMS faculty to teach in a college setting. By the way, the same shortage of faculty is partially responsible for the current nursing shortage. This is but one example of why healthcare education (including EMS) needs to understand business and policy. Take ultrasound.  It’s the current EMS clinical fad on social media.  Everyone wants it.  But has anyone developed a position as to how ultrasound saves money, improves care, or how EMS can get paid for ultrasound.  I’ll wait here for that answer.

And if you don’t believe that healthcare providers (including paramedics and EMTs) don’t need to understand the big picture of healthcare outside the actual provision of medicine to patients, then you’ve illustrated exactly why healthcare administrators often make even more money than the doctors do.

Lead, Follow, or Get the Hell Out of the Way

If you’ve been following any EMS news as of late, you’ve read about the position paper that paramedics should have a minimum of a two year degree. The position paper was issued by the National Association of EMS Educators, the National EMS Management Association, and the International Association of Flight and Critical Care Paramedics. The position paper was peer reviewed and published in the academic journal Prehospital Emergency Care.  Shortly thereafter, what could charitably be called a rebuttal was issued by the International Association of Firefighters and the International Association of Fire Chiefs. Needless to say, the fire service, with some notable exceptions, has little interest in advancing EMS except as a continued source of revenue and mission creep.

So, you ask where our national “voice for EMS” was and what they had to say. Basically, what they said was that there were competing positions worthy of further study. In other words, they took no position.  Regardless of my feelings about the IAFF, the IAFC, and the fire service in general terms, the fire service took a position and they advocated for what they believe to be in the best interest of their members and their trade. I’ll give them respect for that.  And they’ve, by and large, been successful in crafting public policy to their benefit.  The NAEMT?  Not so much.  They took no position. As the famed Texas liberal populist Jim Hightower once said, “There’s nothing in the middle of the road but a yellow stripe and dead armadillos.”

One can argue that by taking no position, the NAEMT took a position in favor of the status quo, which may actually be closer to the IAFC/IAFF position which can be summed up by Pink Floyd, “We don’t need no education.” In all candor, I do think there are significant challenges and hurdles that face EMS if we advance to a degree requirement and that such challenges need to be seriously discussed, especially with higher education leaders.

But NAEMT is an enigma in the world of professional associations.  NAEMT’s primary connection to most members is its development, marketing, and delivery of a plethora of card courses, which are NAEMT’s primary revenue source. NAEMT’s lobbying efforts are primarily directed at the Federal level, while the majority of EMS regulation and legislation happens at the local and state levels. The one clearly identified national level solution, namely a change to how the Centers for Medicare and Medicaid Services (CMS) funds EMS, doesn’t appear to be on NAEMT’s radar. For me, as an EMS provider, the main benefit that NAEMT provides me are member discounts.  NAEMT’s real challenge is that it claims to represent any and all with an EMS certification. As I’ve said before, there’s not a ton of common ground to be found between everyone in EMS.  A flight medic working in rural Nevada has very different needs and wants from their professional association than does a firefighter/EMT who maintains their EMT certification because it’s a condition of employment at their department.

Maybe it is time to realize that NAEMT doesn’t speak for EMS.  And just maybe it’s time for paramedics to demand a separate voice for the advancement of paramedics. After all, the American Bar Association doesn’t represent attorneys, paralegals, law clerks, and legal assistants. The American Bar Association represents lawyers and lawyers alone.

Anyone for a National Association of Paramedics? And the acronym also reminds me of many paramedics’ favorite pastime, me included, namely NAP.

It’s time for paramedics to be our own voice and advocate for ourselves.

KISS: Keep It Simple Stupid

When you’re involved with EMS social media, you see a lot of stuff scrolling through.  Some of it, like FOAMfrat, does a great job of making advanced life support and critical care concepts easy to understand. Someone much smarter than me said “Smart people take difficult concepts and make them easy to understand.”

Unfortunately, you also see some material that does the opposite.  A few moments ago, I saw a proposed post for an EMS education group that I help manage.  The post was about a flowchart than an instructor developed for EMT students to assess and manage patients. Unfortunately, the flowchart was poorly laid out and looked more like a bad Microsoft Project diagram for IT project management.  I’d be surprised if the average EMT student could follow it, much less master it.  And if by some fluke they did, they’d be convinced that they had achieved some level of mastery of medicine. (Spoiler alert.  A lot of EMT training is based on the same stuff that our ancestors learned in Boy Scouts or from the green American Red Cross first aid book.)

Friends, whether you’re a new student in a first responder class or an experienced flight paramedic, EMS isn’t all that complex.  Let’s stop trying to make it complex.  For at least some of it, we make it complex so as to justify our ego and sense of self-importance.  The average EMS textbook is written at roughly a tenth-grade reading level.  That fact alone should bring you right back to Earth.

At all levels, prehospital care can be summed thus.  For trauma care: control the bleeding, protect the airway, and get the patient to an appropriate trauma facility.  For medicine: assess, diagnose, treat, and get the patient to the right hospital the first time to fix their problem.  If you can do those things, do two other things as well.  First, be nice.  Second, make the patient comfortable.  Both of these additional guidelines also apply to being nice to the patient’s family, bystanders, and other healthcare professionals.  The only variation between an entry level first responder and a flight nurse will be in the treatment options and assessment tools you have available to you.

EMS doesn’t have to be hard.  But if all of this is still too hard or complex to understand, I’ll leave you with some sage advice that I got from an experienced flight medic the day I got my paramedic certification. “If you don’t know what else to do, it’s a good idea to take the patient to the hospital.”

EMS.  No, it doesn’t have to be hard.

More on the Four Year EMS Degree

So, I’m thinking more about the push for an EMS degree. In theory, I think it’s a great idea. But here’s a couple of observations.
 
The “other countries have it” argument. Those other countries also have a national healthcare system where EMS is integrated into healthcare. We don’t have that in the United States. Additionally, some of these other countries don’t have a tradition of mid-level practitioners that the United States does like advanced practice nurses and physician assistants, so in some of these cases, paramedic providers are stepping into roles that might be filled by other healthcare professionals here.
 
As a corollary to that, much of our EMS is provided by the fire service and by large private EMS companies. The fire service does EMS because it “has to” in order to maintain some justification for its existence. It has no interest in EMS save for staffing and budget. They’re not going to be advocates for EMS. As for the privates, they want low wages and lower educational standards, since they’ve got a long history of churning through employees and needing a steady inflow of new people.
 
Volunteers. Yeah, truthfully, it’s going to be hard to require a four year degree to volunteer on the ambulance. And unfortunately, there are parts of the USA where the local authorities have chosen not to fund an EMS system or there’s not sufficient people to do it. As the old adage goes, you get the EMS system you pay for.
Clinical outcomes. Everyone talks about evidence based medicine, including me, until they don’t like what it says. Is there any evidence that a more educated paramedic provider has better clinical outcomes. Australia and Canada both have college-educated providers and that’s become the norm there. Yet, these paramedics often have a more limited scope of practice than many locations in the United States.  Is there any evidence to indicate that American paramedics with a lower educational standard and (often) a broader scope of practice have worse clinical outcomes than their more educated foreign colleagues? As a further question, would a four year degree expand the current scope of practice for American paramedics?  As a liberal arts graduate myself, I believe the real value of a four year degree comes from the critical thinking and communications skills that a core liberal arts curriculum develops, but the majority of EMS degree advocates seem to believe that only a four year EMS specific degree is going to “save” EMS.

Actual logistics. Let’s assume that we do decide to put in a degree requirement for paramedics. Let’s further assume that it’s going to be a four year degree. How many degree programs exist? Are there sufficient faculty with an “appropriate” terminal degree in the field to satisfy the higher education accreditation authorities?  And on that note, what is an appropriate terminal degree for EMS?  Would we now end up inadvertently or intentionally creating a doctorate in EMS education?  Would current EMS educators be ineligible to continue what they’re already doing? The demand for nurses and nursing education has already created a shortage of nursing educators.  What would EMS education do to meet that demand on day one?

What would happen with an actual EMS degree requirement?  The skeptic and cynic in me says that most places wouldn’t have degree-educated paramedics.  Instead, the “powers that be” will do one of two things.  They will continue the current paramedic education and call it something else.  Or they will water that down even further and create another “paramedic light” certification. See also: Rhode Island’s EMT-Cardiac, New York’s Advanced EMT-Critical Care, NREMT Intermediate-99 (thankfully being phased out), Virginia’s EMT-Intermediate, or Iowa’s “paramedic” based on the NREMT I-99 standard (the actual “full” paramedic in Iowa was called a “paramedic specialist). And I will make you a bet that the majority of large EMS operations in this country will immediately default to providing service at this “paramedic light” level.

 

If we want degree educated paramedics and believe that’s for the best, we’re going to need to answer these questions.  And we’re also going to need find the funding for this. That probably means getting the primary payer of EMS services, the Federal government, to change Medicare/Medicaid so that EMS systems are paid for treatment and services rendered rather than just transport mileage.  But to do that means that we’re going to have to be more involved in the political process rather than the occasional appearance on a designated “lobby your politician” day where you wear a uniform that looks something like a third world dictator. The truth be told, increased EMS education and increased EMS reimbursement are like the chicken and the egg.  I don’t know which comes first.

 

I’d also point out something said by a former EMS director of mine.  He said he’s paying paramedics (and EMTs) what he can afford to pay them, not what he wants to pay them.  Again, until reimbursement changes, there’s no magic source of increased paramedic compensation, even with higher education.

Before you think I oppose an EMS degree, let me say that I don’t.  I believe that a four year degree is appropriate for a medical professional. I also don’t know that all of the advocates of an EMS degree have fully thought out the impact of such a requirement, even if gradually phased in.

I believe that our current America EMS system may be like Churchill’s definition of democracy. Churchill said that “Indeed it has been said that democracy is the worst form of Government except for all those other forms that have been tried from time to time.…”  I believe that we may find this to be equally true for American EMS if we suddenly change our educational paradigm without considering the consequences.

These concerns and this rant was brought to you by a mostly proud graduate of a certificate granting paramedic program who also had a bachelor’s degree in liberal arts followed by a graduate and a professional degree. Higher education taught me to think. Paramedic education taught me to do. And coming into a paramedic program with a college degree taught me to think and consider what I do as a paramedic.

On The EMS Degree

So, because of a prominent fire chief’s article against EMS degrees, all of the usual EMS advocates are coming out for a gradual phase-in of a degree requirement. And it stands to reason that the fire service wants a low entry standard for EMS.  Most fire departments, especially the larger urban ones, see EMS solely to justify their existence.  Smaller fire departments often see taking on the EMS mission as a way to get increased funding, most of which will go toward the big red trucks and not the ambulance.  In many fire departments, the ambulance is actually called the “penalty box.”

In theory, I’m in favor of a degree requirement to be in EMS, especially at the paramedic level. More education can and should produce better paramedics. But with some experience in both consuming and regulating higher education, I know that giving power to higher education can have unexpected consequences.

So, since this train seems to be gathering some steam, let me throw out my conditional support.  I hope the advocates for EMS education and those accrediting college based EMS programs will listen before we hear about these issues arising once a degree requirement is truly and fully implemented.

  1. Grandfather current providers. I’m told that’s already in the works, but requiring everyone to back and upgrade to an EMS-specific degree would likely overwhelm each of these college based programs.  And for those who already have a bachelor’s or higher in a field outside of EMS, it would be unnecessarily repetitive.
  2. As a condition of accreditation, college-based EMS programs should be required to explicitly state how they plan to meet the needs of EMS students, especially those who are currently in the workforce. Such a commitment should address hours that the courses are offered, locations of the courses, transfer-ability of hours for non-EMS specific courses, and availability of clinical sites.  If you ask why I have a paramedic certificate instead of a paramedic degree, I’ll give you a simple answer.  The community college based program serving my area only offered the paramedic program on a full-time basis during daytime hours only.  With an outside career and already having three degrees, attending a certificate-only program was a no-brainer.
  3. Distance education is a must.  It stands to reason that those against an EMS degree will use the “poor volunteers” as a stalking horse to protect those who stand the most to benefit from poorly educated EMS providers — namely the fire service and the larger private EMS systems. Ensuring that EMS degree programs have distance learning AND nearby clinical rotation sites will ensure that rural and volunteer systems have their needs addressed — and eliminate one more argument against an EMS degree.
  4. In an ideal world, I’d like to see some sort of promise or commitment of an alternate entry degree program for those who already have a bachelor’s degree or higher. Such a program should be tailored to get people the scientific background they need for prehospital medicine (primarily anatomy and physiology) and the coursework necessary to function as a paramedic.
  5. Finally, the accrediting bodies need to ensure that these commitments and promises from higher education are kept ongoing. It will be entirely too easy to start backpedaling once the initial accreditation occurs.

I sincerely hope that those who advocate for an EMS degree take this in the spirit in which it’s meant — a reasonable way to ensure that we actually accomplish the goal of creating better educated paramedics and not solely in guaranteeing higher education a continued revenue stream. If we don’t plan now to address the needs of EMS providers and foresee unintended consequences, we are guaranteed to create even more of a shortage of providers (although some might argue that’s not an entirely bad thing) and creating a group of providers with significant student loan debt to go into a field not known for the highest wages.

We have one chance to get this right.  Let’s make sure that happens.

“Dr. Dunning, I presume?” said Mr. Kruger.

An ongoing topic of discussion on EMS social media is the Dunning-Kruger Effect.  Wikipedia defines the Dunning-Kruger Effect as “a cognitive bias wherein people of low ability have illusory superiority, mistakenly assessing their cognitive ability as greater than it is.”  Over the past few days, I’ve seen some great examples of EMS’s collective Dunning-Kruger Effect.  I also call these moments “not knowing what you don’t know” or “doubling down on dumb.”

The greatest exhibit that I can present to illustrate EMS’s exhibition of the Dunning-Kruger Effect comes from a self-promotion post by a critical care transport educator.  This educator, while promoting a post from JEMS about a Texas EMS system’s decision to adapt their protocols to prevent ventilator-induced injuries, breathlessly exclaims “ICU care begins in the STREETS! i expect my medics to be BETTER than EM and ICU attendings. ALWAYS. Period.” (Note: capitalization error was taken directly from the posting.) In the spirit of self-promotion that afflicts so many EMS “celebrity educators,” the post goes on to promote his recent conference appearances where he discussed using ultrasound to identify lung injuries and adjust ventilator settings.

Here’s the thing.  I don’t know how good or relevant his presentation is. And we all have to make a buck. And if you don’t promote yourself, no one else will.  But there’s probably not a single paramedic out there who’s better than an attending emergency medicine or critical care physician/intensivist.  Having said that and having my own experiences to guide my opinions, I will say that there are many paramedics who can assess a patient and rapidly treat a critically ill patient better than a physician without emergency medicine or critical care education.  Heck, that’s the  primary purpose of critical care/retrieval/flight paramedicine. When a patient is critically ill in a remote setting or an outlying hospital without specialist resources, that’s why you have critical care transport capabilities.

And yes, a critical care medic is probably better than an EM/ICU attending at certain technical skills.  Notice I said skills.  Most physicians don’t deal with vent settings.  Why?  Because in an ICU setting, there are others to help with such things. The physician has their eye on the big picture.  General Patton might not have been the tank driver than an individual sergeant was.  He didn’t have to be.  He did have to know exactly how to rout the enemy on the battlefield and accomplish large objectives.  Similarly, a HVAC technician probably knows more about fixing a faulty air conditioner than does a mechanical engineer. But I can almost guarantee you that the mechanical engineer knows more about how a HVAC system works and fits into a larger picture than a technician does. Likewise, I have a good friend who’s a state trooper.  I can assure you that he’s better than me, a lawyer, at knowing the intricacies of DWI law.  But he’s probably going to have a harder time putting all of the law together to get a complete picture.  Technicians, like many of us in EMS, excel at particular technical skills, hence why they’re technicians.  Professionals excel at the big picture, synthesizing multiple sources of information, acting on said information, and leading a team to solve that problem, almost like a conductor leading a symphony orchestra. (Heck, in the emergency room, look at how a resuscitation is run.  The leader, usually a physician, is rarely performing skills, but rather leading others in what needs to happen.)

Yep.  EMS often illustrates the Dunning-Kruger Effect with our belief in our own expertise.  But I can’t completely blame us.  Over the past few days, I’ve also seen ham-handed attempts by EMS educational programs to engage in education on EMS social media that illustrate President George W. Bush’s infamous question, “Is our children learning?” One community college based EMS education program shared a viral news video of a police officer being administered Narcan for an “exposure.”  Unfortunately, the initial posting by the educational program was posted without context and showed a breathing police officer being administered Narcan for a possible exposure to a stimulant, most likely methamphetamine. As even the lay public is learning, administration of Narcan is indicated for respiratory depression secondary to an overdose of an opiate/narcotic.  In other words, a conscious, breathing patient doesn’t need Narcan.  And an EMS educational program should definitely know better.

But that may not be the worst.  Late last week, a nationally known bachelor’s degree program in paramedicine shared a guest blog post from one of their students. The article was about the controversy of allowing paramedics to intubate.  Well and good.  The topic is definitely worthy of further discussion, especially considering the limited access that many EMS education programs have to clinical sites for live intubation practice. Yet, the article soon disappeared from that college’s social media.  Namely, many EMS providers pointed out multiple misspellings in the post along with dated studies cited (the most recent was over ten years old) and the lack of mention of high-fidelity simulation or more recent science supporting safe intubations through delayed sequence intubation by EMS providers.  Presumably, this blog post was reviewed and approved by the college’s faculty prior to going live. Sadly, when this kind of writing is presented by an educational institution, the writing serves only to reinforce negative perceptions of EMS by the rest of the healthcare community and remind them that the “ambulance drivers” aren’t yet at the same level.

The truth is that EMS does a good job at its core mission.  We excel at providing urgent and emergency care in the out of hospital setting and using a public safety skill set to do such. Our knowledge of the medical field is an inch wide (unscheduled out of hospital care) and a mile deep in that field.  Let’s own that field for ourselves and quit trying to prove how smart we are.  Inevitably, when we stray too far afield and when we keep calling attention to ourselves, we too often illustrate the Dunning-Kruger Effect.  These moments don’t advance EMS.  On the contrary, they remind us why everyone except for EMS providers get to make decisions about what happens to and for EMS.

 

Cleared To Practice, AKA: The License To Kill

I booted up the computer fully intending to write a long screed, aka rant, on the issues currently facing Austin/Travis County EMS, its medical direction, and their relationship with the multiple county first responder agencies and their ability to provide EMT-Intermediate, oops Advanced EMT (showing my age) and paramedic level care.  I’ll still comment on that, but in terms of ATCEMS’s model being an example of one of two extremes of the EMS field training or credentialing process.

This cartoon/meme has been making its way around EMS social media and has popped up on my Facebook feed more than once already today.

Having been in EMS for roughly 14 years now, I’ve seen a variety of methods of providing field training.  They run the gamut from “here’s the keys” to “you’re repeating your paramedic clinicals with us for the next six months.”  As with anything in EMS, we run between two extremes and rarely find the “Goldilocks” point of being just right.

In some EMS systems, the FTO and credentialing process exists in name only.  At one unnamed EMS service, my official FTO process consisted of one ride with a field training officer for twelve hours.  Since I’d been off the truck for a while before starting there, I asked for more time before I even got that.  I got a shift before that where I was officially riding as a third crew member, until the paramedic FTO didn’t show up. Combine that with a chest pain call and the EMS director showing up on scene and asking if I was comfortable with taking the patient 40 miles and my field training process existed primarily on paper.  Of course, when you’re at a rural service that’s already short on staff, much less advanced providers, a field training process seems like a luxury that you can’t afford.  In my opinion, that’s a risk management nightmare.  When a clinical (or operational) failure happens — and it will, the discovery process that a lawyer will engage in will expose these shortcomings and present them to a jury of twelve citizens who couldn’t figure out how to get out of jury duty.

Then, there’s the other extreme.  Let’s take a large, unnamed third service EMS system that’s had an extensive process for bringing on new paramedics.  For many years, that process consisted of several months of a new hire academy then a field training process of several more months.  In short, the process to become a paramedic in this system became a virtual repeat of paramedic clinicals. Then a different medical director came in and decided that there were “too many paramedics” and required new hires to function at a modified EMT level for one to two years before being eligible to “promote” to paramedic.  Let’s now throw in the dozen or so fire departments in the county that provide EMS first response. Ever since before I got into EMS, this EMS system was unwilling to credential first responders above the EMT level. That’s their prerogative. But don’t say you’ll allow it and then make a process that’s so obtuse and arbitrary that it’s a virtual impossibility to credential. The previous medical directors and the department’s clinical management created this mess and they’ve now given the fire departments the rationale to create their own EMS programs. In fact, said county (cough, Travis County, cough) just created its own medical direction to give the county fire departments the ability to run their own paramedic first response program.  And that doesn’t even include two of the fire departments that have created their own paramedic-level ambulance service.

There’s a saying in the law that those who seek equitable relief must come to the table with “clean hands.”  In this case, I have to say that neither party have clean hands.  The EMS system wanted to be the sole provider of advanced life support in the name of “patient safety” and other benevolent sounding reasons for turf protection.  The various county fire departments want paramedic first response and in some cases, transport, to justify their budget and existence and to satisfy the various firefighter union locals that want their members to be an “all hazards department.” In short, to quote Mel Brooks as the governor in Blazing Saddles, “Sheriff murdered! Innocent women and children blown to bits! We’ve got to protect our phony-baloney jobs, gentlemen.” Fire codes have dramatically reduced the number of fires out there.  In Texas, many of the fire districts are funded by property taxes. Also in Texas, there’s a healthy skepticism of government and taxes.  Without EMS call volume, many citizens would wonder what they’re paying a fire department for.  Personally, I’d have much less heartache about the county’s decision to provide its own medical direction for the fire departments if this outcry for separate medical direction had been occurring for years, rather than over the last couple of years that have also been associated with the virtual elimination of volunteer response in the county and the addition of a second tax district in some of these fire districts to “support EMS.” If I feel for anyone, it’s the current medical direction of the EMS system.  They’re passionate about good medicine and supporting the practice of good prehospital medicine.  They’re also in the unenviable position of fixing a system that believed its own public relations for too long and had frayed, if not outright violated the trust of its supposed “partner” first response agencies.

So, what is the happy medium for field training and bringing on new people?  I don’t have studies or statistics to support my general concept of what works.  What I know doesn’t work is handing someone the keys to the controlled substances and saying “Good luck.”  But I’d also question the value of a lengthy process that is a virtual repeat of paramedic clinicals.  In theory, the certification exam for initial certification should provide some assurances of entry level competence. (That in itself is an argument for another day.)  In my ideal world, I’d argue for a field training and credentialing process that is competence based, rather than based on calendar days, clock hours, or getting a certain magic number of certain patient populations.  And in some cases, we’re rarely going to see certain patients in the field.  That means access to a skills lab and/or simulations and scenarios. The process should focus heavily on the unique clinical aspects of that particular EMS system, whether in regards to airway management, medications, or other uncommonly encountered interventions. The process also needs to focus on the operational aspects of being a provider in that system. How many of us haven’t been taught which channels/talkgroups are on our radios?  That, along with resupply, fueling, and documentation requirements often get overlooked in the FTO process. As much as we need to ensure clinical competence, we also need to ensure that a new medic (at any certification level) in the system knows what’s supposed to happen to make good patient care happen.  And let’s not even discuss transport destination determination, which is regularly overlooked.  Getting the right patients to the right hospitals is a core function of EMS and neither initial EMS education nor the processes to bring a new provider into an organization usually address this.  As a result, we routinely end up taking critically ill patients to hospitals incapable of caring for them.

I’ve ranted for a while and I appreciate the indulgence.  The short version is that, like much of EMS, field training and bringing new providers on board a system is a collection of bad practices and extremes. We can do better.  Both our profession and our patients (aka: customers) deserve it.