An Open Letter to the EMS Media

Posted on July 2, 2014 Written by

Ambulance Chaser here.  Overall, I’m a huge fan of EMS media, both online and print, and making EMS information available online to our fellow professionals.  However, I’ve noticed a disturbing trend in several of the EMS websites and publication.  The articles related to law and EMS legal issues tend towards sensationalism, inducing panic and fear amongst providers, click-bait, or stirring up business for the attorney writing the article.  Articles on liability tend to report on isolated, extreme cases out of trial court verdicts or settlements, which do not create binding law anywhere.  And more than one article has ended with information about how to contact the attorney-author for more solutions to the problem they happen to be writing about.  And we know that HIPAA and privacy issues are routinely invoked as bogeymen waiting to trap unsuspecting EMS providers, when we all know that realistic common-sense measures address most compliance issues.  But that doesn’t drive up “clicks” on the website nor clients to the lawyers to purchase a tailor-made compliance handbook and checklist.

And let’s not even talk about the constantly invoked specter of losing your license, getting sued, or gasp, going to jail.  Yes, EMS provider liability exists.  (Honestly, in my opinion, I think more providers should be sued for some of their acts.)  But the liability for EMS providers and EMS systems is a creature of state law in the overwhelming majority of cases.  Continually citing an attorney who practices in one of the worst possible states for tort liability is at best, fear mongering, and at worst, disingenuous.  It’s as self-interested as for a CPAP vendor to write an article on how and when to use CPAP.  Heck, most of the publications put that kind of obvious infomercial in a “special supplement” to the magazine.

And heck, we’re ignoring several of the big issues in the legal arena that continually “bite” EMS — wage and hour claims, employment discrimination claims, tort liability for vehicle operations, and compliance with state administrative regulations.  But of course, it’s much “sexier” to write about some case where some medic in West Cornfield got sued because of a bad outcome for the patient.  Posting an article like that, of course, brings out the legal experts who populate Facebook and social media.  And that drives up the clicks on the website.

For EMS to progress, we are going to have to develop our own core of “experts” in fields related to EMS, including law, politics, and policy.  At the risk of sounding exceedingly self-interested, I believe I fit into that role.  I am one of the few attorneys who’s actively practicing both law and paramedicine.  I bring a focus on addressing and managing risk to legal issues, including those in EMS.  Additionally, with much of my career being in state government, I have a real understanding of the political, regulatory, and advocacy processes that many in EMS do not possess. (If you’ve read my blog in the past, you know my thoughts on what’s right and wrong on our efforts at advocacy and politics.)

I’m not asking for a column or a position (although I’d certainly be open to it).  What I would respectfully request as an reader as well as a practicing EMS provider is that we demand the same excellence in media addressing EMS legal issues as we would clinical issues.

Sorry for what seems like a more self-interested post than usual, but, to a large extent, what the EMS media is publishing as legal education is just not what most providers need.

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

Paraprofessionalism

Posted on June 18, 2014 Written by

Got into another great discussion online earlier about all the additional things that paramedics could do, if only they’d be trained to do them.

That’s the problem.  Professionals don’t just do things.  They know which things to do, when to do them, and they know more than one thing to do for a variety of problems.

In my “real” life away from the ambulance and the blog, I’m an attorney. I know a lot of different things about the law, including things about the areas of law that I don’t practice in.  (The bar exam is a general test of legal competence, not specialization, and rightfully so.)  Yes, it’s entirely possible to create a business entity or a will using software.  It’s also equally possible that said computer program or even a paralegal might not catch some subtle nuance of tax law or community property law that would require changes to the document you’re asking for.

The point is that professionals have a breadth of knowledge about their field.  Paraprofessionals have been trained, usually by learning skills and protocols, how to deal with a variety of situations determined to be “routine” to their career field.  In other words, for paramedics, we learn how to deal with trauma, cardiac emergencies, respiratory difficulty, and a few other so-called common emergencies.  We learn some basic skills for dealing with them such as some forms of airway management, defibrillation, medication administration, bandaging, and splinting.  What we don’t know as paramedics is what we don’t know that perhaps a physician might know.

Thus, as a professional in another field outside of emergency medicine, I cringe a little when I hear my fellow paramedics say how much more they could do if only someone would give them the training.

For any paraprofessional to be trusted to “do more,” there has to be the trust from the overseeing profession.  How do we acquire that trust?  To me, the answer is twofold — we continue to educate ourselves and we recognize our limitations.   Please note that I say education, not training.   A trained chimp can put a tube in a hole.  An educated professional knows when to put the tube in the hole, which kind of tube to put in which kind of hole, and if a tube in the hole is even the right solution to the problem.  And let’s not even go into whether the hole in the patient is the main problem.

As long as EMS continues to advocate that we be trained to do more piecemeal rather than becoming more educated, we will remain paraprofessionals.  Sadly, in many cases, that also means that the rest of the medical world (and perhaps the public) continues to see us as ambulance drivers.

 

Filed Under: EMS, EMS 2.0, EMS Education

Trust, but verify?

Posted on May 26, 2014 Written by

Recently, there’s been a fair amount of discussion about continuing education in EMS.  Having to maintain licenses in two very different professions gives me some unique perspective. (At least I think so…)

For EMS providers in Texas, there are several ways to maintain ones certification. Retesting is an option.  There’s also an option for a refresher course, although I rarely see them offered.   Texas also allows for renewal through continuing education hours or by maintaining one’s National Registry, which presents its own options for continuing education hours or retesting.

To add to this, for either Texas or National Registry, the continuing education hours have to be spread out over certain content areas.   At the most abstract level, this makes sense because most EMS providers rarely get to choose the patients, illnesses, or injuries they encounter.

Now, on top of these requirements, which are overall rational and, for the most part, are practical to maintain (We’ll leave out NR’s arbitrary limits on online CE hours), some EMS systems maintain their own additional requirements for continuing education.  The most onerous I’ve seen require providers to maintain certain “card courses” and to complete a minimum number of hours of CE each year, regardless of what recertification option the individual EMS provider chooses.  These hours are verified on a yearly basis by the submission of the respective CE certificates. This same system requires all of its providers to maintain a CPR card and a PHTLS (That’s “PreHospital Trauma Life Support” for the non-EMS readers) card.  Paramedics are also required to maintain a pediatrics card course card and an ACLS card.  To their credit, though, this EMS system also has some relatively advanced protocols.

The State Bar of Texas provides the following guidance regarding “minimum continuing legal education:”

Every active State Bar of Texas member must complete a minimum of 15 hours of accredited CLE during each MCLE compliance year.

    • 12 of these hours must be in accredited CLE classes
    • 3 of these hours must be in legal ethics/legal professional responsibility
    • 3 of these hours, including 1 hour of legal ethics, could be in self study.

That’s it.  No description of what the courses have to include or address, although the State Bar does have an approval process for CLE classes.  No mandates, aside from ethics, as to what attorneys need to study up on, although most attorneys either take classes on topics relevant to their practice or their personal interests.  And in my twelve plus years of practicing law, I’ve never seen an employer mandate certain classes for attorneys or mandate a certain number of hours.  (Of course, if the employer is paying for the course, they will only pay for courses that they think are appropriate.)

So, when you look at it solely from the continuing education standpoint, ask yourself, which of these two careers is a profession?  And more importantly from the EMS side, does your EMS system really trust you, protocols aside, if they have to tell you exactly what courses they expect of you and how many hours you need each year and want to see the certificates each year?  Granted, there are probably specific people who’ve caused such policies to be enacted, but to me, being a professional means more than being trusted with cool drugs or interventions.  It means you’re trusted and expected to be responsible for your own professional development.  If you can’t be responsible for your own development in your profession, how can your employer trust you?  More importantly, should an employer want employees who need that much direction on how to maintain their certification?

That’s a professional debate worth having.  Let the debate begin.

Filed Under: EMS, EMS 2.0, EMS Education

Feeding a kiddo

Posted on May 19, 2014 Written by

Over the past few years, we’ve heard a ton about childhood obesity.   Heck, the current First Lady has made it her crusade.  Objectively, we all know that the RIGHT thing to do is feed our children a healthy, balanced diet without junk food.  But have you tried doing it?  Heck, have you even tried doing it yourself? (To throw my political gauntlet down at the so-called Food Police of the Nanny State, you can take my Coca-Cola Super Big Gulp from my cold dead hands!) At some point, many of us give up and say it’s better for the kid to get some nutritional value and caloric intake from junk food than it is for the kid to starve from not eating the healthy things.

So, you ask me what this has to do with EMS?  It’s elementary, my dear Watson.  EMS educators, EMS administrators, and EMS conference staff face the same challenge.  What do medics need to know?  What skills and knowledge are they lacking in?  But what are these medics willing to pay for and/or sit through?

You see this when you look at the EMS conference agendas.  For the vast majority of these conferences, the attendees are going on their own dime.  Therefore, to a great extent, the free market rules.  Granted, states and the National Registry do mandate that certain topics be covered, but even with that, there’s a lot of wiggle room, although some EMS systems do require that their providers maintain certain “card courses.”  Card courses are a whole different rant, though.  (To me, continuing education means that you’re acquiring new knowledge, not just repeating the same lectures and skills on a 2-4 year rotating basis.)

So, while you see comments abound about how EMS needs to improve or learn more in certain areas, you don’t necessarily see the EMS conference world striving to embrace these concepts.  Practice on high quality CPR?  Rarely seen, except in the exhibit hall at a vendor display in the context of selling some device that’s alleged to provide CPR feedback.  Discussion of treating respiratory emergencies?  Not so much.  Photos of nasty car wrecks?  Yeah.  Plenty of those.  Tear-jerking, maudlin stories about how EMS is special?  Yeah.  We’ve got those at the conference.

So, here’s the challenge for us as EMS advocates and EMS educators.  We’ve got to find a way to make the critical knowledge palatable for the masses.  We’ve got to make it relevant.  Otherwise, we remain where we are; where continuing education is little more than repeating the same materials ad nauseam.  And we wonder why there’s people falsifying CE attendance? I cannot condone academic dishonesty, but it’s little wonder it occurs when the culture of continuing education is to provide the same knowledge over and over again on a two or four year basis rather than to provide new education continually.

Oh, and by the way, Happy EMS Week.

 

Filed Under: EMS, EMS Education

Paramedicine. The challenge.

Posted on May 8, 2014 Written by

I’ve been reading some comments on my blog today.  The commenter is also an EMS blogger.  He happens to be an EMT who’s currently back in school to become a physician’s assistant.  He and I have been engaging in a bit of a debate about the role of BLS versus ALS in prehospital care. From my reading (and we all know how perception and tone sometimes get lost on the Internet), he’s one of the people who believes that good BLS care is the critical component of any EMS system.  I respectfully say there’s more to being a good provider than good BLS care.  I also assert that there’s more to an EMS system than good BLS care or good cardiac arrest survival stats.

I’m not one of those types who likes the shopworn EMS t-shirt slogans like “BLS before ALS,” “Paramedics save lives and EMTs save paramedics,” or the all-time classic, “Do you want to talk to the paramedic in charge or the EMT who knows what’s going on?”   First of all, the BLS versus ALS dichotomy, seems to me, to be another example of the inherent bias against education and professional advancement in EMS.  That, somehow, the core principles that an instructor tries to convey via “Death By PowerPoint” in a 120-160 hour training class are the only things that matter in emergency medicine and that it’s admirable, nay, even noble to focus solely on this limited set of medical knowledge.  The “low information voter” of these types claims that’s all they need to know.  The sophomoric (Greek for “wise fool”) EMT advocate claims that the science and studies show that advanced life support care doesn’t make a difference.  The science and studies may provide proof of this conjecture for cardiac arrest care, but that’s the low-hanging fruit of studies for out-of-hospital medicine.  Dead or not dead.  But that’s defining EMS success based on a very small subset of our calls — salvageable patients in cardiac arrest.  (And for success there, we’re better off just putting AEDs in public places and mandating CPR training for the public.)

For better or worse, like much of medicine, what we do isn’t easily quantified into a study.  How can you measure the pain you took away from an elderly patient with a hip fracture that you administered Fentanyl to prior to moving them?  How do you measure the symptom relief you provided to a congestive heart failure patient with CPAP and nitroglycerin?  These anecdotal differences are why medicine remains a learned profession that cannot be distilled into a mere science.  Science gives us the information and knowledge to provide care to another.

Being a paramedic is a mindset.  It’s possessing the full armament of prehospital knowledge.  It’s knowing when to use, and more importantly, not use an intervention.  It’s using the resources you have on scene.  It’s knowing when you need additional resources.  It’s managing your partner, regardless of their certification level. It may even be calling a doctor for a consult or orders.  Most notably, it’s a set of skills, knowledge, and competencies that can’t be learned in a 120-160 hour course.  Heck, in my personal, non-researched opinion, graduating from paramedic school makes you only competent enough to spend the next year or so in a high volume, high acuity EMS system honing your abilities and skills under the tutelage of a mentor.  Nope.  Not a FTO.  Field training is merely orienting the provider to a particular EMS system.  You need the mentorship to learn the craft of being the highest level of care outside of a clinical setting. Paramedic education teaches the fundamental knowledge and skills.  Tutelage under a mentor makes you a master at the job.  It’s the difference between knowing how to perform a rapid sequence intubation and looking at a patient and realizing that they’re in danger of losing their airway.

Paramedicine, or prehospital care, is like all of medicine, more than mere science. It’s the application of scientific knowledge to real people.  And the world of paramedicine adds in the confounding factor of applying this knowledge to people in the nonclinical setting.  The choreography of EMS is the challenge.  Until you’ve picked up the baton as the lead paramedic to conduct the prehospital symphony of your partner, first responders, firefighters, cops, the patient, and hysterical bystanders/family, you’ll never understand the challenge — nor can you understand the sheer joy of it.  If you’re an EMT, pick up the challenge and advance professionally.  Otherwise, I will politely and respectfully ask you to defer to my prerogatives as the lead.  That doesn’t mean that we can’t discuss patient care. It doesn’t even mean that I don’t want to hear your ideas on scene.  What it does mean is that we’re not in a democracy and that with my increased knowledge and responsibility comes the decision making authority.

Thanks for reading, y’all.

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

Starting at the bottom

Posted on May 8, 2014 Written by

Lately, on Facebook, there’s been some debate.  (Or what passes for debate on Facebook — AKA, monkeys flinging poo.) The Facebook EMS forums have been all abuzz about the idea that some EMS systems don’t hire you in as a paramedic and that you have to work as an EMT for a couple of years before promoting into a paramedic position, regardless of your state certification level.

Let me say that I think this is a flawed model.  Do I have the science behind ALS skills retention and the number of ALS interventions out there?   Nope, I don’t.  I won’t even deny that there’s only a few patients who really need the whiz-bang ALS stuff such as intubation, but that’s not all there is to being a paramedic.  But, I think the way to learn being a paramedic is by being a paramedic. And a good paramedic assessment is something you can perform on every patient.  Symptom relief, whether pain management or nausea management is one of those ALS skills as well.  Good BLS skills are definitely the foundation of competent paramedic care, but at some point, the “everyone is an EMT for X number of years” model is going to turn away experienced providers. The BLS skills model also works really well when you have short transport times to definitive care as is the case in Boston and most parts of Austin. (Heck, the Houston Fire Department even recognizes this and tells their EMT crews to initiate emergency transport for any trauma patient they encounter in inner Houston.)

As for me, I was very fortunate to have the opportunity to “grow” as a medic in a very high volume, high acuity EMS system with exceptionally broad and aggressive protocols developed and implemented by a full time medical director.  New full-time medics went through a FTO process before being released as a second crew member.  To be the lead (AKA in-charge) paramedic took an additional FTO process.   As for volunteers, you rode as a third crew member while retaining the ability to practice virtually any skill available to your certification level and, after a period of time, could challenge the FTO process.  For me, that process worked.  It worked quite well.  While I’m no longer with that service, I appreciate my experience and routinely refer back to it with almost every call I run.

There’s no secret about these places (most notably Boston and Austin) that hire paramedics into the role of a basic.  They tell you in advance that’s what it’s going to be.  There’s full disclosure.  If you don’t like that process, you don’t have to apply.  And while I don’t have the numbers, my supposition is that a lot of experienced providers aren’t interested in such a process.  Sadly, many of the younger, inexperienced medics who’d benefit from an extended skills development process and FTO program because of a lack of maturity, both as a person and a provider, also lack the maturity to recognize that they need such processes. Civil service produces a lot of good benefits for medics — namely a well-defined process for HR issues.  What it also produces is a relatively static culture that promotes from within, and without careful attention from management, promotes an insular groupthink.

In conclusion, I’d say that the model that Austin and Boston use is the model they’ve decided on.  If you don’t like it, don’t apply.  But to those services, when you have an extended FTO and promotional process, you have to recognize that you’re unlikely to attract experienced medics.  It becomes a self-fulfilling prophecy.  You can’t attract experienced medics to such a system, so the system becomes even more rigid to adapt for inexperienced medics requiring more initial training and mentoring.

Yep, when the only tool you have is a hammer, everything starts looking like a nail.

Filed Under: EMS, EMS 2.0, EMS Education

Two contradictions in healthcare.

Posted on May 3, 2014 Written by

1) The nursing lobby continues to push for advanced practice nurses to have more privileges, but continues to oppose EMS providers being able to practice community paramedicine or function as EMS providers in the emergency room.  Why?  Because that’s supposedly unsafe for the patient to be seen and treated by someone with less education than a nurse.   Funny.  That’s the same argument that physicians use to say that advanced practice nurses still need limitations on their scope of practice and for physician oversight.

2) You know the people in EMS who claim that EMS providers are legally prohibited from providing a diagnosis because only a physician can?   Funny, aren’t they providing legal advice without the benefit of passing the bar exam?  And by the way, their legal opinion also happens to be wrong.

Critical thinking.  It’s contagious.  Here’s hoping you catch it.

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

Is EMS about to keep itself irrelevant?

Posted on May 1, 2014 Written by

With much ballyhoo and publicity, we’ve heard a ton about increasing educational requirements for EMS.  The National Registry now requires a paramedic candidate to have graduated from an accredited paramedic program.   What does accreditation mean?  Speaking cynically, it means that an education program has gone through a process where it has created a big ol’ (Yep, “big ol'” is a Texas colloquialism, so deal with it…) policies and procedures process that may or may not have anything to do with academics and/or successfully creating baby paramedics.

And at least some of the EMS world is clamoring for a degree requirement for paramedics.  They’re convinced that a degree for paramedicine will enhance both pay and professionalism.  They point to nursing as an example where this has happened. Perhaps.  Maybe.  Respiratory therapy now has degree programs and, if I remember correctly, its pay hasn’t skyrocketed like nursing.  Correct me if I’m wrong.

What concerns me about the EMS education trend is this.  We are continuing to look at an EMS degree as a technical thing.  More hours in the hospital.  More hours in the classroom learning what paramedics already know how to do.

What EMS hasn’t done is grow a future generation of EMS leaders and thinkers.  We need paramedics who know public health, public policy, management, the political and regulatory processes, and dare I say it, the legal realm. EMS is a business, whether it’s publicly run or a private enterprise.  Johnny and Roy may know how to intubate, but if Johnny and Roy can’t make a budget, deal with HR, and deal with Capitol Hill, Johnny and Roy are going to remain the bastard stepchildren of healthcare.

If we’re going to have a debate about a paramedicine degree, let’s be sure that we know what a paramedicine degree should contain.  And let’s start growing a cadre and a core of EMS subject matter experts in all of the fields that touch EMS — not just experts in EMS.

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

Be the change. Infiltrate.

Posted on April 24, 2014 Written by

So many people have complained about the lowest common denominator (or “low information voter” AKA LIV) tendencies in EMS and EMS management (both clinically and operationally) ad nauseum. What we haven’t done is begun to fix it. The path is deceptively simple. Infiltrate. Infiltrate. Infiltrate. There are tons of committees, focus groups, etc. out there. Imagine if each of these committees had a strong advocate for higher EMS standards on them advocating for change or at least showing the way.

Currently, I’m up at NREMT helping review EMT exam questions. Watching a medic’s eyes pop out at reading a sepsis protocol that involves more than fluid resuscitation has been worth the trip alone.  I don’t blame him.  I blame his regional system for maintaining a lowest common denominator EMS system.  I blame the fire departments and private services that want a lowest common denominator system for the express purposes of lower wages and/or ease of training.

Get involved. Infiltrate. Be the Fifth Column that corrodes the lowest common denominator mentalities from the inside. If nothing else, it adds to your personal contact list.  And just maybe if we have the advocates for high quality EMS networking with each other, high quality EMS becomes the denominator.

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

Endangered Species

Posted on April 15, 2014 Written by

So, I recently read an article online in Fire Apparatus Magazine bemoaning the state of EMS. Because, as we all know, the most current information on emergency medicine comes from a magazine that shows pictures of big red shiny trucks.

When you go through the article (I’m not going to link it because I don’t want to give this guy any more legitimacy), he raises the standard argument that fire chiefs and large EMS system managers always use as their stalking horse in their arguments to keep EMS educational standards low — or even lower them. Yep, that’s right. The mythical rural EMS volunteer who will disappear if we change the science and/or add one more bit of knowledge to their already overflowing brain.

I feel more than qualified to address this issue. I’ve spent the majority of my EMS career as a volunteer at both the EMT and paramedic levels with both fire-based systems and third service models. I’ve worked urban, suburban, and rural. The majority of my experience has been in combination departments where paid and volunteer medics work side-by-side. And to the premise of this article, I say, “BULL.” Well, I said more, but this is a family-friendly blog.

I’m more than tired of using the overworked rural volunteer provider as a straw man. First, regardless of whether you draw a paycheck or not, an EMT or paramedic certification is the same. In many states, you can’t say the same for a paid versus unpaid firefighter. Second, in my experience, volunteers are some of the most motivated people out there when it comes to seeking continuing education and opportunities to advance their medicine. In the rural service where I currently volunteer, we have an active continuing education program consisting of monthly online classes as well as a full panoply of “card courses” covering resuscitation, cardiac care, medicine, trauma, pediatrics, and tactical medicine. Our medics, at all levels, routinely exceed state mandated training requirements. I’d further note that several of our paramedics are volunteers who work in outside professions and maintain licensure in those professions as well. Furthermore, come to any of the big EMS conferences. There, you’ll notice a disproportionate number of volunteer providers, especially compared to those employed in large EMS systems.

In short, Chief Haddon of the North Fork, Idaho Fire Department is wrong. Volunteer EMS providers can, will, and do exceed educational requirements and expectations. Give them a chance and you’ll find out. And if you don’t believe me, I’m extending a personal invitation to come down to Texas. I’d be happy to introduce you to some volunteers who actively seek to improve themselves professionally for the benefit of their patient. Heck, I’ll even treat to BBQ.

I’m not expecting a visit, though. It’s a lot easier to use the myth of the overworked, overwhelmed volunteer EMS provider who will go away if we add one more class. Sadly, this “don’t need to know it mentality” usually only benefits the “mongo mentality” of “you call, we haul” that seems to hold back EMS. The worst part is that the same departments and administrators who bemoan increased EMS education can be seen at all of the structural fire conferences. Maybe its time to have more volunteer EMS systems and less volunteer fire systems?

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