No matter how you look at it.

Posted on December 27, 2015 Written by

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.

Filed Under: EMS, EMS 2.0, EMS Education

System Abuse. Yet again.

Posted on December 21, 2015 Written by

System abuse.  That’s a term we commonly hear in EMS.  And as soon as we start talking about system abuse, the talk invariably turns to EMS providers’ favorite solution for system abusers.  Namely, the idea that EMS providers should be able to refuse transport to system abusers.

First of all, what constitutes a system abuser?  We all know at least one of these creatures by name in our local service area. Yet, in my eleven years in EMS, I’ve yet to hear an agreed-upon definition of system abuse.  It’s like the definition that former Supreme Court Justice Potter Stewart created for pornography — namely, that he knew it when he saw it.

Next, failing to provide treatment/transport to a so-called system abuser is a recipe fraught with peril.  EMS medical directors, as a matter of risk management, have to write their protocols and policies to mitigate the risk of a poor decision being made by the worst provider in the EMS system.    We’ve all seen or heard about “that guy” in our local system.  The guy who missed a STEMI.  The guy who doesn’t manage pain.  The guy who took a trauma patient to a local community hospital.  Bluntly, when the doctor (and the lawyers) think about it, the safest, easiest, least risky decision is to encourage every crew to transport (or at least offer to transport) every patient every time.

The average EMS provider has no idea of what they don’t know.  Most EMS education programs excel at creating the impression that, by teaching a set of skills to “fix” some very acute medical emergencies, the average EMS provider is “doing everything that a doctor does.” After any period of time on the street working as an EMS provider and seeing the reality of our calls, we find our assessment skills in particular make us ill-suited for the reality of modern EMS — namely, the unscheduled delivery of primary care, urgent care, and the occasional emergency care.

I don’t have a solution for system abuse.  However, I can tell you where the solution starts, at least in my eyes.  To comprehensively address EMS system abuse, EMS providers need to work with EMS physician medical directors to develop a local protocol defining system abuse, providing alternative dispositions for these patients, and providing comprehensive medical oversight to mitigate the risk of deviating from the current accepted paradigm of taking every patient to the hospital emergency department.

My cynical side says that instead, one of two things will happen.  One, we’ll just keep complaining and wishing that we had the ability to turn away patients.  Two, some vendor will come up with some technological “solution” that just makes things more of a hassle than to just provide a ride to the ER.

As much as I love the practice of prehospital medicine, I sometimes think that the worst enemy of EMS is the average EMS provider. The solution to system abuse and almost every other EMS challenge is to raise the standard of what constitutes the average provider.

Filed Under: EMS, EMS Education, EMS Legal

Dear EMT Student

Posted on December 18, 2015 Written by

Early this morning, I brought my father to the ER.  He’s getting up there in years and he’s pretty sick.  You came into the room with several of the nurses.  Having remembered my ER clinicals, I slid over and introduced myself to you and told you what was going on with dad.  With his congestive heart failure acting up, I suggested that you might want to listen to his lungs.  You told me that you had “already gotten all of your lung sounds.”  Apparently, I should’ve caught onto that from the fact that you weren’t even carrying or wearing a stethoscope.  You never introduced yourself to me, my father, or anyone else in the room.  You never laid hands on the patient, did an assessment, or performed any skills.  However, I did see you spending most of the rest of the night sitting at the nurses station cutting up with the unit clerk and the techs.

Congratulations, kid!  You’ve succeeded. You’ve illustrated so much of what’s wrong with EMS.  You came to a clinical unprepared.  You showed me through both your actions and attitude that you’re merely marking time and there to get the very minimum done.  You showed a clear lack of interest in furthering your knowledge above and beyond the very minimum entry level of one of the most minimal entry level jobs in healthcare.  And most importantly, you’ve confirmed to me and probably a good chunk of the hospital staff all of the rumors about EMS and EMS students in particular.

You’ve done a great job of harming our profession.  I only have two hopes for you. One, you hopefully get with the program before you end up harming or killing someone with your obvious lack of interest in medical care. In the alternative, I hope the National Registry exam does its job in keeping out the clearly incompetent.

And by the way, for the record, you’d have never started a clinical with me as your preceptor.  Your stethoscope is a required part of your uniform at your program.  You’d have been sent home with an explanation of why; I’d have notified your education program; and I’d have told you to reschedule.

When we allow students like you to progress, all we do is continue to shortchange our profession and retard the growth of EMS.  To my fellow EMS educators, it’s time to abandon “no medic left behind” and start holding students accountable.

Filed Under: EMS, EMS Education, Rants

Some random observations on what we do

Posted on December 16, 2015 Written by

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.

 

Filed Under: EMS, EMS 2.0, EMS Education

Another example of not talking to the lawyers.

Posted on December 12, 2015 Written by

One of the recurring themes that I notice about EMS and about EMS management in particular is that people regularly avoid asking a lawyer for advice and instead rely on what they think a lawyer would say.  Of course, without the benefit of law school, your legal opinion is about as dangerous as relying on a Facebook post promoting raw cinnamon or vinegar instead of chemotherapy or surgery to treat cancer.

I regularly see these examples of legal sophistry masquerading as “protecting the organization from liability.”  I usually have a knowing chuckle at these instances. But today, one just captured the prize for “what the heck are they thinking?”

I have a good friend who’s a paramedic for an unnamed Scandinavian EMS operation that’s expanding into the USA.  Said friend of mine is also one of the smartest people I’ve ever met with an EMS certification.  He reminds me a lot of myself a few years ago.  He’s smart and eager to improve EMS.  Like the old version of the Ambulance Chaser, though, he’s also impatient and more than willing to tell you that your’e wrong.  When he becomes older, wiser, and more tactful, I have no doubt that he’s going to change EMS.

Recently, he posted a picture of teaching his partner some airway management techniques.  Shortly after that, he was disciplined for “unauthorized training.”

Yep.  Let that sink in.  Unauthorized training.  What kind of corporate nimrod came up with that?  Clearly not someone with a either the benefit of law school or any current knowledge of EMS practice.  When the literature says that EMS providers are terrible at airway management, that airway training is lacking in EMS initial education, and that continuing opprtunities to practice and master airway management are lacking, we have some corporate lackey discplining a medic for maintaining mastery of his profession and for sharing his knowledge with another medic.  Corporate is more worried about the training being authorized than about the medics under their employ receiving any training in airway management at all.  Risk management, indeed.

All I can to those people is that the Ambulance Chaser’s unofficial opinion is that you’re a bunch of Falcking idiots.

Filed Under: EMS, EMS Education, EMS Legal

The Five Most Dangerous Words In EMS

Posted on December 7, 2015 Written by

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.

Filed Under: EMS, EMS 2.0, EMS Education

Challenges to Mobile Healthcare

Posted on November 30, 2015 Written by

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.

Filed Under: EMS, EMS 2.0, EMS Education

Here, this is your license to learn

Posted on November 19, 2015 Written by

I recently heard a good friend of mine say that she’s “just” a basic, because she recognizes the limits of what she can do — and presumably, what she knows.

Well and good. The first step in becoming a proficient provider, in my view, is to know that you don’t know what you don’t know.   That applies to everyone from the newest first aid provider to the most experienced subspecialist physician.

But the next step is to realize that while scopes of practice may be a limit, there’s no law, statute, regulation, or administrative rule that creates a scope of knowledge.  In other words, there’s no limit to what any provider can learn.  Will they be able to do a new skill?  Probably not.  But having the knowledge doesn’t always reflect itself in a skills base.

So, my advice to each of you is simple.  Keep learning.  Challenge yourself with increasing your knowledge base.  EMTs shouldn’t be afraid to read a paramedic text.  Paramedics should be reading medical texts. (In my opinion, it’s imperative to have both Tintinalli’s and Harrison’s on your bookshelf if you’re an advanced provider.) The purpose of continuing education, which we as EMS providers keep forgetting, is to enhance our knowledge, not merely repeat the same classes to check off the same requirements.

Maybe, just maybe, when EMS providers recognize their certification card as a license to learn, not merely as a sign of achieving their career objective, we can be recognized as EMS professionals.

The Texas EMS Conference starts this weekend.  I’ll be there with my license to learn.  Will you?

Filed Under: EMS, EMS Education

The continuing education sham

Posted on June 26, 2015 Written by

Every now and then, I see online EMS continuing education providers engaging in some pretty unethical behavior.  I’ve seen multiple sites reposting copywritten blog posts from other EMS providers.  I’ve also seen resuscitation card courses (ACLS, CPR, PALS) offered from questionable accrediting bodies that aren’t accepted by most state EMS agencies, most employers, or the National Registry.

The majority of us in EMS accept this because we don’t take continuing education seriously.  It’s merely another requirement to be pencil-whipped through, just like the truck check.

The real purpose of continuing education SHOULD be to keep current with the science, practice, and art of medicine.  Yet most of us sit through whatever our employer provides and/or mandates and find the cheapest options for everything else.  I’d surmise that less than 20% of EMS providers have attended an EMS conference of any form.  I’d doubt that most providers participate in the FOAM concept of free open access medical education.   Rather, con-ed becomes an exercise in minimal effort exerted to maintain minimal standards. And in most cases, con-ed becomes another ritual in which the masses repeat the dogma they learned from their instructors and, as such, maintain their certification for another cycle. As such, the majority of resuscitation science has devolved into pressing play on the DVD and parroting back cycles of drug doses.

Say what you want about college degrees or pay raises.  This right here is a large example of why we aren’t considered a profession.  In other words, this is another example of why we don’t have nice things in EMS.

Filed Under: EMS, EMS Education

Couple of book reviews

Posted on March 30, 2015 Written by

Apologies for the lack of posts lately.  Between a massive contract at the “real” job and having a ton going on in my offline EMS and personal lives, I’ve given the blog a bit less attention than it should have.

However, I’ve recently added several books to my EMS library that I believe the thinking medic should own.

The first is called Avoiding Common Prehospital Errors.  It’s a collection of short (2-4 pages) articles about various aspects of EMS care as written by various physicians, nurses, and EMS providers.  For the average EMS provider, especially those in the average EMS system, it’s a game changing book.  The book contains most of the recent science (published in 2013) out there and more importantly, each article is thoroughly cited with even more references.  If you’re looking to institute evidence-based medicine in your EMS practice, the book, with a few exceptions, does an excellent job of advancing science as opposed to dogma. As such, when the contributors share bad medicine in a few instances (naloxone for altered mental status and a slight dose of “backboard everyone” paranoia), these instances stick out like a sore thumb.  I still highly recommend it.

Virtually everyone in EMS has, at one point or another, had a field guide or pocket guide.  With the rise of smart phones, these are going the way of the dodo bird.  However, one field guide still stands out.  I cannot help but recommend Medic’s Little Helper.  While the book is Canadian, and as such, contains some metric measurements that US EMS providers don’t use, especially for blood glucose levels, it’s a thorough reference that covers a variety of topics in EMS from the most basic reminders all the way to the critical care arena.  It barely fits in the pocket of cargo pants, but it’s a useful companion to have.  Also, highly recommended.

Filed Under: EMS, EMS Education
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