My Sermon to You

Posted on February 14, 2015 Written by

I’m not the world’s most religious guy.  But I just awarded myself a new title. I’ve accepted ordination as a reverend in the EMS Church of the Painful Truth.  And for my fellow followers of the gospel of the truth that EMS is the practice of medicine, I deliver to you my first sermon.

I direct my preaching at the wayward masses.  Because, after all, it’s the sinners who need salvation, not the choir.

Here’s who and what holds EMS and EMS education back.  Students who consistently fail to take responsibility for their own learning; the fictional belief that some specific study guide or app will magically allow them to pass NREMT; the belief that the NREMT exam is difficult; low entry standards for any EMS education program; and an army of mindless drones bleating along about how “you can do it.” And of course, the belief that the test shouldn’t matter so long as you can do skills and you want to be in EMS. I am fully expecting to be called a meanie, unsupportive, a paragod, and probably several other names. Here’s one thing though. I’ve achieved my EMS certification. The secret? A little bit of intelligence, some common sense, and a four letter word that’s forbidden to so many unsuccessful EMS candidates – WORK.

If EMS is that important to you and you truly feel called to deliver medicine at all hours of the day or night, then EMS should be important enough to master, much pass an entry level test designed to measure minimal competence to practice your craft safely.

No more excuses.  Join the EMS Church of the Painful Truth.  All you have to lose is your dogma and all you have to gain is the knowledge that, contrary to what the rest of our craft says, you are a medical professional.  And the Kool-Aide is safe to drink.

Filed Under: EMS, EMS Education, Rants

Medical Practice By Cliche

Posted on January 30, 2015 Written by

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.

Filed Under: EMS, EMS 2.0, EMS Education, Rants

About That License

Posted on January 27, 2015 Written by

I get it.  Becoming an EMT is a big accomplishment for many, even including me years ago.  It was pretty cool to know about things and do things that the “rest of us” don’t get to do.  And the same is true if and when you make the jump to paramedic.  You might even get some neat t-shirts to flaunt that you’re an EMT or a paramedic — and especially proud of it.  The really neat part is that your state gives you a piece of paper or plastic that identifies you as an EMT or paramedic, which means you’re “officially” able to do EMS things.

I have another card in my wallet as well.  It’s my card from the State Bar of Texas that identifies me as a Texas attorney.  It means that I get to do things that others can’t do.  It’s a bit of a long road to get one of these cards.  It takes a four year undergraduate degree followed by three years of law school.  Then, the licensing exam.  It’s a two and a half day exam, given only twice a year.  And it means I get to give legal advice and represent (and counsel) clients about the law.   When you learn the law, you learn that few things are in a vacuum.  A statute alone means very little.  You need to look at the definitions that might be found in other places.  You need to look for relevant court cases applying the statute.  You need to look for regulations implementing that statute. And then you figure out how all of these things apply to the facts of your client’s case.

So, when as an EMT or paramedic with the benefit of a four hour medical legal lecture that was read by another EMT or paramedic who’s not an attorney and the slides were prepared by the textbook feels that they know the law enough to read a statute back to me and claim that’s what the law is, I do get a bit offended.  In my world, that’s the same as some attorney who’s not a paramedic hooking someone up to an IV because they saw a YouTube video.   Just like there’s more to being an EMT or paramedic than knowing how to do some random skill(s), there’s more to being an attorney than reading back a statute.  That’s why it takes a while to become a lawyer.

And that, my friends, is why I get offended when some EMT feels that they know what I know based solely on reading a statute and misinforming their colleagues.

In conclusion, I’m incredibly proud to be trusted by my state as both a paramedic and an attorney.  And I will continue to protect both of my professional identities from those who haven’t been admitted to practice in either profession.

Filed Under: EMS, EMS Education, EMS Legal, Rants

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

Posted on January 20, 2015 Written by

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.

Filed Under: EMS, EMS 2.0, EMS Education, Rants

We make a difference.

Posted on January 5, 2015 Written by

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.

Filed Under: EMS, EMS 2.0, EMS Education, EMS Legal

Negligence for Dummies

Posted on December 9, 2014 Written by

Ok, I’ve adapted this lesson from a Facebook post I’ve made, but I’ve given some thought to explaining some legal concepts that impact EMS and this is my first effort.  Please let me know if this is helpful and if you’d like to see other legal topics explained.

Please understand that while I’m a lawyer, I’m not your lawyer and my explanation will be pretty generic, because the law is going to differ in each state.

There are four elements that are required to prove up a negligence case. You must have all four of these for the plaintiff to win their case. Duty, Breach, Causation, and Damages.

Duty — This means that you owe a responsibility of reasonable care to another while performing an action which could cause harm. Generally speaking, duty does not attach until you are either dispatched to the patient or you assume patient care. Abandonment a separate claim/lawsuit that occurs when you assume patient care and relinquish said care prior to being relieved by a provider of equal or higher training/certification.

Breach — In short, this is breaching the standard of care. Standard of care means what an ordinary, reasonable provider of similar skill and experience would do in a similar situation. While we often discuss state protocols, card courses (CPR, PHTLS, etc), textbooks, and expert witnesses, ultimately, these are all factors and evidence that will be assist the fact-finder in the case (the jury in a jury trial or the judge in a bench trial) establish what the standard of care is.

Causation — In other words, did your acts and/or omissions cause the harm to the plaintiff?

Damages — Was there actual harm that can be quantified to the plaintiff? Did the plaintiff suffer physical, economic, or psychological damages that the trier of fact (whether the jury or the judge) can quantify into monetary damages?

As I mentioned at the beginning, you’ve got to have all four of these elements for the plaintiff to succeed with a claim for negligence.

I’m happy to help explain further, but since I’m not your lawyer and, unless you’re in Texas, I’m not licensed to give legal opinions for you, I’d prefer not to discuss specific case(s) that you might’ve been involved in.

Hope this helps!

Filed Under: EMS, EMS Education, EMS Legal, Law

Not nice. Politically incorrect. And probably true.

Posted on December 7, 2014 Written by

The biggest problem with the average EMT education program is that it seems to create a false sense of smug competence in that 120-160 hours of vocational training deems you competent to function as a medical professional. The real learning and progression to professionalism is when you realize that you don’t know what you don’t know.

Because let’s face it, when your “education” consists of war stories from your instructor, clinical shifts where you get a gold star for showing up, and a bunch of shopworn sayings like “BLS before ALS,” “treat the patient not the monitor,” and “give ’em a diesel bolus,” suddenly you realize your medical knowledge and skills are much closer to a Boy Scout first aid provider than they are of a board certified, residency trained physician.

The positive news is that, despite the efforts of some, it’s pretty hard to kill someone with only minimal training.  Of course, so long as mastery is defined by completion of a certain number of hours rather than mastery of the topic, then EMS will be to medicine what shop class is to engineering.

Filed Under: EMS, EMS Education, Rants

Not Everyone Gets a Trophy — or a Patch

Posted on October 28, 2014 Written by

No matter what your view is on what constitutes a “legitimate” request for an EMS response, we all agree (or in theory, should agree) that a patient calling 911 is experiencing a bad day. Even the lowest acuity call deserves a response from an educated, competent, and ideally, compassionate, caregiver, regardless of certification level.

As I look at some of the Internet and Facebook forums devoted and dedicated to EMS, I see a lot of posts full of spelling errors.  I see a lot of posts asking questions that either shouldn’t be asked in a public forum or should be considered common knowledge in emergency medicine.  And of course, I see posts begging for help on passing the National Registry exam on the student’s sixth and final attempt. Many times, I ignore these posts and shake my head.  Sometimes, I let my snarky humor emerge.  My good friend and fellow blogger, EMS Artifact, used to give these shining exemplars of the future of EMS a Mickey D’s job application as a helpful hint.

Why do I not always encourage little Johnny or Susie to “be all they can be” and be a real lifesaver?  Simple.

Emergency medicine is too important to lower our standards to the point that everyone gets a trophy — or a gold colored National Registry patch.  This is why I refuse to coddle students, tolerate poor patient care, or be supportive to the person who asks for help on passing Registry on their sixth attempt.   We’re in the business of caring for the weakest and most vulnerable of society.  That demands high standards.  And if you’re complaining about the lack of professional respect or financial stability in EMS, then we should be setting the standards for excellence — not minimal competence.

If this makes me a paragod or an arrogant prick, then so be it.  Maybe we need just a few more paragods or arrogant pricks in EMS.

Filed Under: EMS, EMS 2.0, EMS Education, Rants

(Another) reason why EMS isn’t taken seriously

Posted on September 29, 2014 Written by

EMS providers love to claim that “EMS isn’t taken seriously” by you-name-the-other-healthcare-profession.  And we’re right.  We rarely are taken seriously.  I’ve complained before about some of the reasons why.  (See also: T-shirts with flaming skulls and sayings about “Racing the Reaper” and “Doing Everything That a Doctor Does at 80 miles per hour.)

But today, I stumbled on another reason why we shouldn’t be taken seriously.   EMS professionals of all levels fail to grasp the science behind what we do.  I’m not talking about an EMT being unfamiliar with the Krebs cycle or even a paramedic not being able to explain why Trendelenburg is bunk.

What I’m talking about is more fundamental.  It’s about a failure to understand the scientific method, which subsequently adds to the continued issues with medics lacking critical thinking skills or understanding research.  This morning, I saw at least two experienced paramedics on Facebook hawking pseudoscientific woo as diet/health supplements.   Either they’re con artists or they lack the basic scientific literacy to understand that there’s ZERO science or evidence behind the overwhelming majority of these products.  Let’s not even discuss the amount of EMS providers who are vaccine deniers.  I won’t even give them the courtesy of invalidating their beliefs.  To me, vaccine deniers are the medical version of Holocaust deniers.

And then, there’s the other extreme in EMS.  We have the pedants who claim to be advocates of science and “evidence based medicine.”   All too often, though, these “experts” will immediately advocate massive changes in medical practice based on one journal article.  Sometimes, these experts don’t even critically analyze the article.  Patient who receive morphine in acute coronary events have worse outcomes?  Their solution?  Ban morphine administration.  Critical takeaway — most patients who receive morphine in acute coronary events receive morphine only because the nitroglycerine failed to relieve their chest pain.  Did it ever occur that the patients with more acute pain might be having a more extensive event?  Nope.  To the nattering nabobs of negativity who self-appoint themselves as “EMS research experts,” one journal article is enough to limit the EMS skills arsenal or drug formulary.  Yet, these same experts usually want multiple studies to enhance EMS skills or drugs because “the science hasn’t been proven yet.”  Folks, it’s a rare case when one journal article should change your practice.

I’ve blogged before about the shameful state of EMS legal education.  It’s somewhat understandable as EMS isn’t run by attorneys.  (And that’s probably a good thing, excluding your favorite blogger not named Kelly Grayson….)  But EMS is medical practice.  And medical practice is supposed to based upon science.  For EMS providers of any level to not understand the scientific method and inject a healthy dose of skepticism to most claims is to fail as medical providers.  And that, my dear minions, is yet another reason why we’re ambulance drivers and not healthcare professionals.

Filed Under: EMS, EMS 2.0, EMS Education, Rants, Uncategorized

Core Maxims of EMS

Posted on August 22, 2014 Written by

Here are a few of my core observations and beliefs about EMS.

1) You can never go wrong catering to the lowest common denominator of EMS.  The success of Facebook groups like The Most Interesting Ambulance Crew In The World and t-shirts with themes including cutting clothes off of patients continues to prove this maxim.

2) Until EMS engages itself in political advocacy, our future and agenda will always be subject to the whims of others, whether it’s the nursing lobby, the fire service, or unelected bureaucrats in your state’s health and human services bureaucracy.

3) We’re always looking for the next BIG thing that will advance EMS.  Today’s flavor du jour is “community paramedicine.” As much as I like the idea, I’ve yet to see an easily defined skill set or a knowledge base that’s portable across jurisdictions.

4) As long as we continue to define ourselves by a skill set (e.g. I’m a paramedic, therefore I intubate), we will, at best, remain a vocation.  Honestly, right now, we’re a collection of skills more or less randomly put together as “things that might be useful to know in a medical emergency.”  (Otherwise, how could some universities offer a 2 week program for nurses and physicians to become paramedics?)

5) What passes for our education prepares us for emergency medicine.  What our call volumes is typically represents urgent and primary care with a few actual emergencies on occasion.

6) There’s a joke about leaving two firefighters in a room with a ball bearing and that it would be broken in an hour.  Leave two medics in a room for an hour and there will be a clique of “cool kids” and a rumor mill be going.

7) Patients don’t know how good your medical skills or knowledge are.  They are more than capable of figuring out whether or not you actually care for them.

8) If you’ve seen one EMS system, you’ve seen one EMS system.  At least in the USA, there’s no one ideal model of EMS system or service delivery.  What’s going to work in Presidio, Texas sure isn’t going to work in downtown Seattle.

9) Any EMS service that constantly bangs the PR drum to tell you how progressive they are probably isn’t all that progressive.

10) There are a few EMS systems out there that aren’t worth keeping.  Start over from scratch.  Washington DC. Cough. Washington DC. Cough.

11) The current EMS educational models and examination models give a de facto veto to whichever state has the lowest standards.

12) The most overlooked aspect of an EMS student’s educational experience is their set of clinical rotations.

13) Pain management matters.  Having said that, EMS providers need a non-narcotic option as well.

14) As long as people are willing to accept substandard working conditions, substandard working conditions will exist.  In other words, if you don’t like parking on a street corner for 12+ hours, don’t work there.

15) You cannot build an EMS system without taking care of your medics.  Period.

16) In the overwhelming majority of cases, communities get the EMS system they pay for. A suburban bedroom community that chooses to only have a BLS volunteer service shouldn’t act surprised when a crew isn’t available at 3:00 PM.

17) Until the average EMS provider can use, pronounce, and spell medical terminology with something approximating intelligible English, we shouldn’t be surprised when our healthcare colleagues seem hesitant to trust us with high-risk procedures like intubation and surgical airways.

18) The follow-on to #17 is that we need to prove ourselves competent with our current skill-set in emergency medicine before we can legitimately expect to be entrusted with the expanded scope of practice in community paramedicine or critical care.

19) We’re fooling ourselves when we have providers who want EMS to be able to refuse to treat or transport “low acuity” patients while at the same time parroting the phrase, “We don’t diagnose.”

20) If we truly have a national EMS exam and a common educational standard, reciprocity across state lines should be a virtual given.  Artificial barriers and hurdles established by state licensing entities represent one of the banes of EMS — turf protection.

Final one….

21) Turf protection wars (fire versus other delivery models, private versus public, BLS versus ALS, ad nauseum) will end up proving Ben Franklin’s adage about hanging together rather than hanging separately.

 

Filed Under: EMS, EMS 2.0, EMS Education, EMS Politics
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