On Rhode Island

Posted on December 18, 2019 Written by

Point of personal privilege here. Because I’m about to rant. And seeing as this is my blog, that’s why you’re here, right?   Sorry, not sorry, that there aren’t any Baby Yoda or cat memes here.

There’s a ton of people posting memes making fun of Rhode Island EMT-Cardiacs and their supposed inability to master advanced airway management.  Most of these memes are being posted by people who like to fashion themselves the fountains of all EMS wisdom and knowledge.  Further, some of these same types believe that their fecal material is non-odorific.

I don’t blame the average Rhode Island EMT-Cardiac for this.  (FYI, for those of you unfamiliar with the certification, the scope is somewhere between Advanced EMT and Paramedic.)  They’re working in a system that they likely didn’t develop.  And at least some, including at least one friend who I’ve literally broken bread with, are competent providers.

I do blame a toxic political culture in Rhode Island where the IAFF, fire chiefs, and politicians hold more sway over the regulation and development of the state’s arguably dated EMS system than do physicians. Rhode Island has its share of EMS issues, including an outsized influence by the fire service, fire chiefs, and fire unions and nowhere near enough involvement from EMS physicians.  Rhode Island’s limited provision of ALS care (EMT-Cardiacs aren’t paramedics.  Sorry, not sorry for that truth.) and it’s relative lack of medical dispatching place Rhode Island severely behind the times in terms of prehospital medical care.

And let’s talk about those snarky edgy social media players criticizing Rhode Island EMS.  They claim to be science-based and evidence-based.  Fine.  I’ll give them that. But what they don’t get is public policy or the political process. Nor do they truly get “just culture,” which is (rightly) supposed to be all the rage in medicine these days.  Nope.  It’s much easier to make memes and make fun of the line-level EMS providers than it is to engage in even superficial analysis and note that Rhode Island’s EMS system and the politics behind it are the problem.

I’ll give Rhode Island credit for one thing.  At least someone in Rhode Island is looking at data.  Granted, the political culture up there is doing what ossified political types do — ducking and distracting, but the data is out there.  I wonder where the data is on actual clinical performance and outcomes for some of these “smarter than you” types posting memes and claiming to be “scientists.”

In summation, for all of y’all who are poking fun at individual EMS providers, I’ll leave you with some lyrics from Ice-T.  “Don’t hate the player, hate the game.”

Filed Under: EMS, EMS Politics, EMS Social Media, Rants

Rural EMS and the Rural Hospital Crisis.

Posted on November 5, 2019 Written by

One of the best pieces of advice that an attorney gave me as I entered the legal profession was that I should read the news every day.  He told me that you never know what future cases might be in the news.  Being a bit of a nerd for politics and policy, I still follow that advice.  This morning’s review of the news led me down a trail where I ended up reading an article from a liberal/progressive publication about rural hospitals in Texas closing.

The article had two accounts of patients dying because a rural hospital in northeast Texas had closed. One patient apparently had a heart attack and the other patient had a brain aneurysm. And the article quoted family members and local politicians as saying that these people wouldn’t have died if the little hospital had still been there.

If you’ve got any experience (or even baseline knowledge) of emergency medicine and EMS in particular, you’ll know that rural hospitals have limited capabilities.  In fact, both of the cases in question likely could  not have been stabilized at a local rural hospital. Both of these patients required extensive specialist interventions that would typically be found in a larger city.  In fact, taking these patients to a rural hospital without specialist capabilities would have actually delayed care.  The well-intentioned laws designed to prevent dumping of patients into an emergency department (EMTALA) would have required the initial hospital to find a specialist facility to accept this patient and then transfer care to said facility. Even in other cases, patients admitted to a hospital may require specialist care or intensive care treatment that is largely unavailable in rural hospitals.

A properly trained, staffed, and equipped EMS system would have been able to recognize that these patients required care well above and beyond local capabilities.  Properly trained and equipped paramedics would be able to provide the same resuscitation and stabilization abilities AND transport directly to the appropriate specialist facility.  As I’ve heard said more than once, there’s no magic resuscitation fairy waiting at the hospital.  Resuscitation measures are the same, whether in an inpatient setting or out of hospital.

The solution to healthcare in rural America is not to engage in a quixotic quest to reopen rural hospitals with limited capabilities and delaying access to definitive, specialist care.  The solution is to channel that funding toward expanded access to primary care, specialists making regular visits to rural communities, and establishing a robust EMS system that provides comprehensive and competent paramedic level care. With an aging population that’s poorer than average, a strong EMS system can absolutely make a difference in rural healthcare. And our EMS voices need to say such.  We are the experts on emergency care outside the hospital.  Period.

Journalists know how to write.  They rarely know medicine.  Or policy.  In this case, their advocacy may well harm patients by delaying definitive care in favor of local care.

Filed Under: EMS, EMS Politics, Politics

And So It Goes

Posted on August 14, 2019 Written by

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.

Filed Under: EMS, EMS Education, EMS Politics

A Farewell to the NAEMT

Posted on January 28, 2019 Written by

Dear Mr. Zavadsky:

First of all, I appreciate your offer to reach out last week after my blog entry regarding my views on what appeared to be NAEMT’s no position of a position statement on the ongoing discussion regarding a degree requirement for paramedics.  Unfortunately, our schedules have yet to match up.  But I did find the explanation provided by one other NAEMT insider to be interesting to say the least – namely that the NAEMT position statement had been in the works for a while and was unrelated to the competing positions from other EMS and fire organizations regarding a paramedic degree requirement.  I might have been willing to believe such a statement had NAEMT (or you) provided such a background statement in conjunction with NAEMT’s position statement. However, such an explanation at this point, when prior opportunities were available, strikes me much more as an attempt at damage control than providing a nuanced policy statement. The fact that NAEMT hasn’t publicly clarified this statement speaks even louder as to the organization’s unwillingness to take a position. I stand by my original position that a degree requirement is worth exploring for paramedics, but will also require significant planning and buy-in from higher education stakeholders.

I was almost willing to view this position statement as merely another failed opportunity for NAEMT to advocate for the EMS profession until today.  As you know, last week, New York City Mayor Bill de Blasio spoke against EMS pay increases for New York City EMS professionals in comparison to Fire Department, Police Department, and Sanitation Department employees claiming, “The work is different.”  EMS social media roared. NAEMT was, once again, silent. Today, however, the National Association of EMS Physicians released a position advocating for EMS pay to be commensurate with the responsibilities of EMS providers. Again, I note – NAEMT, the supposed voice for “advancing the EMS profession,” was silent.

Two such notable flubs in the span of less than two weeks speaks volumes as to the culture and leadership of NAEMT.  I’ve criticized NAEMT before for a variety of issues, namely a focus on quixotic efforts to lobby the Federal government for programs that may not benefit our profession as a whole, a lack of advocacy at the state levels, and an overreliance on revenue from card courses.

More than anything, what I’ve seen from NAEMT is a continued failure to advocate for EMS for fear that it may ruffle some feathers.  What I also see is a culture that has the same usual crowd of EMS insiders and their cronies placed in positions of leadership. (In all fairness, I do have a great deal of respect for you and several of the board members.) This culture has created an organization that is slow to respond to the needs of EMS and to the news cycle as EMS is impacted. When applications for new positions and committee members are sought, it’s always the same names that you always see in EMS.  NAEMT has failed to develop a next generation of EMS leaders and advocates.

Finally, I see an overreliance by NAEMT on revenue from a plethora of card courses. NAEMT’s reliance on said revenue and the partnerships with textbook publishers mean that these largely repetitive card courses are seen as much as a cash cow as they are an actual source of current medical education. I’ve taught Advanced Medical Life Support for years and have even been affiliate faculty for the program.  However, the rise of social media and FOAM efforts means that many continuing education programs on a four-year cycle are, by their very nature, outdated.  Yet, NAEMT produces new courses every year and the publishers produce new updates and required materials on the same basis.

To me, NAEMT’s main benefit consists of the various discounts provided and discounted admission to the EMS World Expo.  While there have been some quality speakers at EMS World Expo, I’d also note that there are many presenters and topics at the conference which do not advance EMS and instead serve the “meets minimum standards” and “lowest common denominator” level of the EMS trade.  Note that I did not say “profession” in this case.

I fully expect that there will be consequences from my communication.  I say this not out of spite, but out of the recognition that my interests as an EMS professional aren’t always recognized by NAEMT.  I will quote another paramedic colleague of mine who says, “I am a member of NAEMSP, but not of NAEMT. I like my money to go someplace useful.”

Accordingly, I choose to speak with a clear action.  I hereby resign my membership in the National Association of Emergency Medical Technicians.

 

Filed Under: EMS, EMS Politics

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

Posted on January 23, 2019 Written by

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.

Filed Under: EMS, EMS Education, EMS Politics

On The EMS Degree

Posted on September 6, 2018 Written by

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.

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

Where To Fix EMS

Posted on September 4, 2018 Written by

We all know the problems with EMS.  Mostly they revolve around low pay, low standards, and unreliable sources of funding.  Easily fixed, right?  Well, maybe.

But there’s an ongoing problem in EMS. Most EMS systems operate under the belief that good clinical skills (or even worse, good clinical outcomes) are the primary determinants of who gets promoted.  Being a good clinician involves more than clinical skills.  And being a good clinician doesn’t mean you’re going to be a good educator or a good manager. Being a good clinician doesn’t correlate with much besides being a good clinician.

What does EMS lack?  And more importantly, what do most so-called EMS “Leaders” lack?  They lack the “soft skills” besides how to read an EKG, intubate, or start an IV. They may have a professional network, but they don’t know how to use it.  They rarely understand politics at any level — from the local government who decides how to fund and provide EMS to the state officials who regulate EMS to the federal officials who determine how Medicare and Medicaid reimburse EMS. They don’t understand the value of public relations.  They rarely understand budget and finance.

Ok, so you get the picture. So what is EMS doing about it?  Well, we’re doing the same thing as always.  We’re promoting folks on their clinical skills at best and most often based on who they know or how much management likes them. We’ve created a system where most EMS employers don’t have much of a career track.  And we continue to tell our best and brightest to move into another medical field, whether nursing, medicine, or physician assistant.

What should we be doing?  Simple.  Let’s actually grow our own EMS leaders and not just the usual gang of experts/idiots who speak at every conference simply because they’re loudly exclaiming they’re leaders.  Let’s encourage the best and brightest to remain in EMS and further their education.  They already know how to be EMTs or paramedics.  What they don’t know is what to do next.  Let’s get people degrees in adult education to become clinical educators.  Let’s get people degrees in business management or public administration so they can effectively manage and lead an EMS organization.  Let’s get people educated in finance to figure out how to keep the crews paid and fuel in the trucks. And maybe even get a few of us into law school and admitted to the Bar.  After all, we’re in healthcare, one of the most heavily regulated fields in the marketplace.  Having someone who knows how to navigate the legal, regulatory, and political landscape might just help advance EMS a bit more than just another guy who says “Narcan” at the right time. And since EMS is a business, maybe having someone with some marketing or public relations skills might help the public (and the politicians) understand that not all EMS is created equally and that, like anything else, you do indeed get the EMS system you choose to pay for.

Or…. we can keep doing what we’ve been doing.  The current results speak for themselves.

Filed Under: EMS, EMS 2.0, EMS Politics

EMS is OUR Profession

Posted on March 20, 2018 Written by

Here’s a great example of what’s wrong with EMS. This morning, I was looking at the webpage for the EMS For Children Improvement and Innovation Center project being administered by Texas Children’s Hospital. The webpage identified twenty-eight staff members assigned to the project.

Of these staff members, only one of them is identified as a paramedic and he’s actually a full-time employee of the state EMS office. The majority of those identified with healthcare backgrounds were either physicians or nurses. We need to quit letting EMS be defined and controlled by people who aren’t in EMS. This is the equivalent of having a bunch of paramedics define oncology care because they do transports.

The truth is that there are EMS professionals with the educational background to be involved in developing the future of EMS and determining our professional identity. There are paramedics with master’s degrees in a variety of fields ranging from the hard sciences to education to public health to administrative fields like business administration, public administration, and healthcare administration.  The National Registry even funds two EMS professionals per year to get a graduate degree in an EMS related field. There is NO reason not to have more than a token EMS presence on committees that define who we are and what we do as a profession.

Instead, through a combination of our own apathy and aggressive encroachment by other fields (cough, nursing, cough), we allow our profession’s path to be charted by those without a real stake in EMS and not necessarily with EMS’s best interests in the forefront. The nursing advocates regularly say that EMS providers shouldn’t do anything that approaches nursing and believe that nursing represents a higher level of education and skill sets.  However, these same nurses readily encroach on the EMS field and insert themselves on almost every committee that determines EMS education and practice.  Try advocating for an EMS professional to even have a seat on a committee regarding the hospital emergency department or the ICU and prepare for the wailing and gnashing of teeth.

A lot of really smart people in EMS regularly advocate for EMS being represented within the US Department of Health and Human Services.  Personally, I believe this will continue the trend of EMS having little, if any, voice of its own.  After many years as a government lawyer, I’ve realized that those who call the shots in the health and human services bureaucracies usually have a nursing and/or a public health background.  I can virtually guarantee that putting EMS in the health and human services system will ensure that nursing and public health controls who we are and what we do.  An EMS office within the HHS bureaucracy will be little more than a token voice that will be run over roughshod by the nurses, public health professionals, and various other “stakeholders” that truly have no stake in EMS.

We have got to control our professional identity and that begins with paramedics being involved in the administration and development of our profession. It’s time to demand that those that define and determine what EMS is at least have an idea of what happens on an ambulance.

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

Couple of Quick Thoughts

Posted on January 25, 2018 Written by

While perusing social media this morning, I noticed a couple of things that bear repeating.  Again.

The same professional EMS committee members are now taking public input on “EMS Agenda 2050.” yet we can’t always even get the core mission of EMS right — namely getting people to a hospital — ideally the right hospital and with the patient in no worse (and hopefully better) condition than we found them. I’d like to fix EMS 2018 before we turn EMS Agenda 2050 into another document forced upon us by the same people who largely created the current mess.

Everyone continues to look for a single silver bullet that will fix EMS.  Education. Increased reimbursement. The latest equipment.  Some buzzword usually involving “data.”  EMS in the United States is a local responsibility provided for in a variety of models.  Imposing and implementing one “magic solution” won’t work.  What works in a compact city like Boston with multiple academic medical centers in a small area isn’t going to apply well to rural Nevada where a small hospital is an hour’s drive.  The reason why our nation’s Founding Fathers embraced federalism is in recognition of the simple truth that one size fits all solutions from a central government rarely work. (See also: IRS, “Affordable Care Act,” and the Post Office.)

The only thing I see more than people in EMS routinely advocating for us to take people to destinations other than hospitals are stories of EMS getting refusals wrong and a patient getting sicker or dying. I say this after seeing, just this week, an article about a child whose parents called EMS to take their child to the ER for the flu, EMS obtaining a refusal, and the child ultimately dying.  Was EMS responsible?  We don’t yet know at this point.  But I do know that taking a patient to definitive care is a large part of what we do.

Most ER physicians will tell you that the hardest decision they make is the decision to admit a patient. That’s coming from a physician with access to labs and imaging and specialist consults. I’m not ready to trust someone with (at most) two years of education, minimal diagnostic equipment, and a short assessment to make the decision that going to the hospital isn’t a good idea.  Yes, there are obvious cases that we can consider “abuse” of the emergency care system. But the lawsuits will result (and they WILL happen) from the patient with vague symptoms who’s relying on the judgment of the lowest common denominator of providers who just wants to get back to their station.

And that brings me to my final thing worth repeating today.  An EMS system is only as good as its worst provider on their worst day.

Feel free to refer back to this post in 2019.  I’m sure it will remain just as relevant.

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

All Politics Is Local: Or an EMS Labor Union and the Kerfuffle

Posted on November 2, 2017 Written by

There’s been a lot of discussion on EMS social media about the contract between the City of Austin and the Austin/Travis County EMS Employees’ Association (AKA: The Union) lapsing. I’m not a medic for ATCEMS, but I feel compelled to wade in as an Austin resident, a paramedic, a public sector employee, a friend of many of the medics in the system, and as someone who was a first responder within the system. I’m going to give this my best effort and will probably not gain any friends as a result. But that’s ok – as the old joke goes – lawyers have feelings.  Allegedly.

This is a system that’s had issues for a while. And this isn’t solely a greedy public employees’ union issue.  Nor is it an issue of terrible management. The truth be told, it’s a horrendous combination of lousy union leadership and equally inept city leadership.  The union leadership has sold its membership one scheme after another as the “one big fix” to the challenges of working in EMS.  I remember several years ago when there was entirely different leadership at the union, EMS management, and even city management.  A paramedic ran for the union presidency on a promise of replacing the current (at that time) 56 hour work week of 24 hours on and 48 hours off with a guaranteed 48 hour work week – for the same pay.  Needless to say, neither EMS nor city management were enamored with the idea of cutting hours for the same pay.  Then the union president raised the issue of “safety.”  That’s an issue that, once raised, can’t be recalled. At that point, the city hired a consulting firm to examine EMS scheduling and the determination was made that many of the stations were too busy to be on 24 hour schedules.  To this date, scheduling and station assignments remain one of the biggest challenges at ATCEMS. A variety of schedules have been tried and active fatigue management policies are now in place.  While the fatigue management policies are welcome and needed (especially after the death of a respected ATCEMS captain who fell asleep while driving), the reality is that all of the scheduling fixes fail to address the underlying problem – a busy EMS system that does not have sufficient staffing or crews, especially in the areas of highest call volume in the center of the city.

The call volume in central Austin also impacts other parts of the system.  Many of the ambulances from the other parts of Austin have to transport to hospitals in central/downtown Austin.  Once those trucks become available as they leave the hospital, they are assigned calls in central/downtown Austin.  The crews call this “getting sucked into the vortex.” Meanwhile, the more outlying areas of the city are without their ambulance – all because no one recognizes the 800 pound gorilla in the room – the central part of Austin with its socioeconomic demographics, the entertainment district in downtown, and two homeless shelters less than two blocks from the entertainment district.  The solution was, is, and remains additional EMS resources in central/downtown Austin.  No other solution is a solution.

And let’s talk about the outlying areas some. Pretty much since the EMS system was created in Austin, Austin has supplied paramedic-level transport for all of Travis County.  Each of the fire departments in Travis County (including Austin FD) have provided first responder services under the protocols and medical direction of ATCEMS. In THEORY, ATCEMS protocols allow for the “credentialing” of these fire departments’ advanced/intermediate EMTs and paramedics to function at their state certification level. The reality is that the credentialing process is very similar (and probably rightfully so) to the field training process that ATCEMS medics go through to be “credentialed” for independent practice.  In actuality, the process exists largely on paper. The process is too long and involved for many departments to commit an employee for this extended period.  And it serves ATCEMS to limit the number of providers above the EMT level.  As a result of this process, its lack of transparency and clear standards, and the underlying motives in limiting the number of advanced providers, ATCEMS has alienated many of the fire departments in the county.  Pflugerville was alienated to the point of creating its own fire-based EMS system and completely separating from ATCEMS.  Two other departments have their own medical direction now for paramedic-level first response.  This failure reflects right back on both ATCEMS leadership and ATCEMS union leadership.  In fact, one union president told Pflugerville that his job was to protect his members. Granted, it’s probably the truth, but at least be politic enough to couch it in terms of patient safety, patient care, and patient outcomes.

If management deals in good faith with employees, there’s little hue and cry for a union, much less civil service protections. Witness the number of Japanese auto plants in the US where workers have actively rejected unionization attempts by the United Auto Workers.  ATCEMS has had a history of employee discontent and morale issues.  I know paramedics from the early 1990s who complained about being assigned to a mandatory overtime shift at the busiest station in the system (and one of the busiest in the US) right after working that same station for the previous 24 hours. As the morale problems continued and several provider suicides occurred, Austin’s previous medical director was replaced by a new medical director who came in from the outside.  One of his first of many arrogant moves was to push for ATCEMS to hire EMTs because he believed that there are too many paramedics in EMS and he didn’t believe there was evidence to support advanced life support providers.  This mindset was that of a physician who seemed to define EMS success by cardiac arrest statistics alone. A new “Medic I” position was created where anyone with an EMT certification or higher would be eligible to apply.  After a period of 1-2 years as a “Medic I,” those with a paramedic certification would be eligible to promote to the “Medic II” position as a paramedic-level provider. Needless to say, this change increased the workload on system-credentialed paramedic providers and also turned off many experienced providers from applying to work for ATCEMS.

While ATCEMS has since replaced the medical director with a much more progressive and aggressive medical director from the Houston area, the Medic I/Medic II model is now virtually codified as a result of ATCEMS moving to civil service. As a result of the continued workplace discontent, the latest “solution” from the union was “civil service.” Civil service would provide for state laws (or a negotiated contract with the city) to govern employee relations including hiring, promotions, and discipline. It has also codified a management team and culture where, other than the department director and medical director, all promotions are from within the department.  And this is a department that is so insular that it still believes its own PR machine about how progressive it is.  In fact, until the mid 2000s, the ATCEMS patch still had “System of the Year 1985” on it.  While other EMS systems have added paralytics for intubation and multiple other drugs and interventions, the bureaucratic inertia of ATCEMS has turned the previous clinical excellence into just another large urban EMS system, albeit without the requirement to become a firefighter. And just like most fire departments where the IAFF rules the roost, the union was created as a result of management strife, but requires on continued strife to justify “this is why we need a union.”

And now the employees are without a contract.  And “this is why we need a union.”  And so it goes.

Filed Under: Austin politics, EMS, EMS Legal, EMS Politics, Politics
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