Well, it’s Monday and it’s the annual commemoration of EMS Week.  This is the week where you’ll likely get some sort of junk food at the local ER, assuming the staff doesn’t eat it first. Your employer may give you some sort of trinkets and there will probably be a couple of extra motivational posters around the station.  All of those are the traditional ways of celebrating our week and honoring what we do for our respective communities.

But I wanted to go a little past that.   I saw something last week that got me to thinking.  Last week, I saw pictures of a bunch of paramedics from a large EMS system undergoing boot-camp style training to become “rescue” paramedics, skilled in rope and water rescue.  And that led to another thought – namely, how many of us add something else to modify the term EMT or paramedic.  Firefighter/EMT.  Special Operations Paramedic.  Critical Care Paramedic. Firefighter/Paramedic. Flight Paramedic. Dive Medic. Community Paramedic. Firefighter Paramedic. Tactical Medic.

It’s absolutely great — and essential — to expand our knowledge and, in some cases, to expand what EMS does to meet our respective communities’ needs. However, the reality is that each and all of those roles fill limited needs.   There are relatively few patients that need advanced life support provided by paramedics rappelling down a cliff or that need care under fire (at least in the civilian world).  The chances of needing to intubate a patient in a radioactive environment are pretty close to nil.

Let’s go back to the famed “White Paper” issued by the National Academy of Sciences in 1966.  That’s the paper that gave the impetus for modern EMS.  It addressed accidental death and disability in the out of hospital setting. From that, EMS has evolved into the practice of prehospital medicine.  To me, what EMS is delivering the practice of medicine, outside the clinical setting, incorporating some aspects of the public safety disciplines to do so.

There’s nothing wrong whatsoever with these additional skill sets.  What is wrong is the explanation that I’ve heard from some of these providers as to why they pursue those skill sets. Time and time again, I’ve heard, “I wanted the additional challenge.”  My continuing belief is that if you do the medicine right, there’s plenty of challenge. Medicine is constantly evolving.  The clinical practice of medicine has changed dramatically in the twelve years I’ve been in EMS.  More and more EMS systems have embraced selective spinal motion restriction, rapid sequence intubation, 12-lead EKG interpretation, and standing orders for pain management.  When I first entered EMS, I’d never heard of ketamine or sepsis, yet both of these are now routine terms I use in my practice of medicine.

On this EMS Week, let’s each make the commitment to each and every one of our patients by doing the core mission that unites us all — providing the best medicine possible. On this EMS Week, commit to being a clinician first and foremost.

Over the last few years, EMS provider safety and health has come to the forefront.  Rightfully so. Whether unreported, under-reported, or just ignored in the past, we’ve recently begun to recognize the threats to EMS professionals of all sorts.  There are several organizations, most notably the Code Green Campaign, who’ve done an excellent job at suicide prevention and mental health awareness in EMS. Other EMS providers have noted the upswing in violence toward EMS responders and have raised awareness and training to address this threat.

However, one of the latest public safety suicides, that of a firefighter/paramedic in northern Virginia, really hit home to me. There are allegations that the medic in question was the victim of workplace bullying and cyber-bullying.

Somewhere, somehow along the way, the public safety world got fed a lie in that hazing and bullying are part of a so-called brotherhood. There’s certainly nothing wrong with some good natured teasing and some ribald jokes (of which I know quite a few).  However, when you’re continually targeting a particular person or group at your workplace, that’s definitely “not cool.”

I’ve been in some organizations, especially when I was younger, where jokes got carried too far.  When I was much younger, I was, for a short time, a midshipman at the U.S. Naval Academy.  I saw hazing.  I experienced hazing.  And all it did, at least in my case, was cause me to reevaluate my decision about a naval career.  There’s no brotherhood in tormenting those beneath you.  And “they did it to us” is no justification for continuing to do the wrong thing.

We’ve got way too many toxic workplaces in public safety.  The behaviors range from bullying to hazing to cliques that control the workplace.  I could spend an entire post on the destructiveness brought on by the cliques of “cool kids” in a workplace that serve to alienate and marginalize everyone else.  When you combine the “cool kid” clique with social media posts where the “cool kids” brag about their weekend exploits and hijinks, particularly with willing and participating members of management, you create a toxic culture where some members of the organization become ostracized.  Whether it’s intentional or just ignorant, it’s the height of hypocrisy to discuss teamwork and have teambuilding exercises when there’s alienation occurring right underneath ones’ eyes.

Between provider suicides, mental health crises, and losing EMS’s best and brightest to other professions, it’s clear that EMS has some issues to resolve.  Resolving those issues is going to require a massive shift in attitude towards how we treat other, towards a real brotherhood (or sisterhood), and making things at the station a hell of a lot less toxic.  It’s time to realize that being a professional is about doing the right thing, not just the fun thing — and it begins with how we treat each other. Let’s have that discussion about how we’re treating each other.  I’m not completely sure we’ll like what we’re hearing.

Every now and then, we get the latest news about some “groundbreaking” study involving EMS or even tangentially connected to EMS.  The older I’ve gotten (and hopefully a bit wiser as well), I’ve come to take most of these studies with a grain of salt.  I present to you a couple of reasons why.

First, most of these academic studies are done where the academic medical institutions are — typically big urban areas with ready access to full-service teaching hospitals. When you have a five minute transport time to a facility where every specialty of medicine is present and each attending physician goes by “Professor,” there is something to be said for rapid transport being treatment.  That goes even more so when your large urban EMS system is comprised, in part, of providers who have little interest in the clinical practice of medicine.

Next, most EMS research seems to have almost a fetishistic focus on resuscitation.  I’d surmise that the reasons are twofold.  First, the research outcomes are easy.  Unlike The Princess Bride, there’s no mostly dead.  It’s either dead or not dead.  It makes for easy endpoints in research.  Second, since American EMS was initially based on accidental trauma and out of hospital cardiac arrest, the resuscitation interest seems logical.

As such, we have ended up with some of the research questioning the value of paramedic-level providers.  And it’s true to an extent.  A BLS provider is perfectly capable of transporting a traumatic injury to a trauma center for the one intervention that matters — surgery.  And in the majority of cardiac arrests, BLS interventions of chest compressions and defibrillation are what matters.  And doubly so in both instances if you live in a large urban area with a plethora of hospitals.

But here’s what little of the research addresses.   Firstly, suburban areas, much less rural or frontier areas, where transport to definitive care is not measured in single digits.  In some rural and frontier areas of my home state, the highest level of medical care available in the county after normal business hours is a paramedic.  In these cases, there’s undoubtedly a benefit to providing the advanced level of care that a paramedic brings — but because there’s no “science” to definitively support this assertion, there’s skepticism at best about providing advanced level care. Additionally, some paramedic level interventions defy easy measurement.  Unlike the outcome of cardiac arrest – dead or not dead – it’s a bit more challenging to quantify and measure symptom relief. “Sir, earlier you described your ingrown toenail pain as 12 out of 10. Now that you’ve had some pain relief, what’s the pain level now?”  Meanwhile, the femur fracture patient says they are fine and don’t need pain management.   Similar measurement difficulties can occur with other medical crises such as respiratory distress and chest pain.   It’s hard to quantify subjective measurements.

What would go a long way toward providing meaningful EMS research for the rest of EMS would be to develop some research consortiums and studies that occur outside large urban medical care systems.  Factoring in the distance to transport to definitive care and removing the maniacal fascination with cardiac arrest resuscitation would be a huge step in providing meaningful data to EMS providers in suburban, rural, and frontier EMS systems.  One thing we know about EMS is that one system solution doesn’t fit all.  It’s time that our research agendas reflect that reality as well.

I’m getting up there in years.  Maybe not as old as some of my friends and mentors, but I’m getting there.  I don’t necessarily look back on the past as the “good ol’ days,” but I do recognize that things have changed — including medicine.  At the most fundamental level, our American system of healthcare, based largely on third party payment of insurance claims, has changed as well.

Years ago, if you got sick, you’d call your general practitioner and he’d make a house call.  As Medicare and Medicaid changed the reimbursement model (and private insurance adopted many of these standards), the house call became antiquated, so your doctor would meet you at their office, even after hours, to deal with an urgent matter.  As this model changed — and emergency medicine advanced — your doctor would meet you at the hospital ER.  Now, if you call your doctor after hours, you’re most likely to hear a recorded statement that says, “If this is an emergency, hang up and call 911 or go to the nearest emergency room.”

The result of this is that emergency rooms are crowded and EMS call volume continues to climb. The response from the emergency medicine world isn’t exactly inspiring.  Numerous individual EMS providers bemoan “911 abuse” for matters that aren’t “real emergencies.”  And now a noted emergency medicine physician-blogger has opined on “the go to the ER mentality of American medicine.”

Economics says that people are fundamentally rational. So, let’s take that approach.  If you have a medical problem and “do what you’re supposed to do,” you call your primary care physician.  With any luck, you’ll be able to get an appointment for an office visit in the next few days. If the matter is VERY simple and resolves quickly, you’re just out the copay for an office visit, assuming you have insurance.  If the matter is beyond the ability of what “evidence-based medicine guidelines” (AKA protocols for primary care medicine) allow for a primary care physician, you can expect multiple follow-up visits, referrals to specialists, and referrals out for lab work and imaging, all with their own separate copays and co-insurance.  Meanwhile, you’ve also lost time from work and your regular life as well because all of these visits have to happen between 8 AM and 5 PM on weekdays. Tell me how agreeing to “play by the rules” of American medicine is rational?

However, if you go to an emergency room, you’ll be seen by a physician trained in emergency medicine, which covers a wide spectrum of medical care.  You’ll also have access to lab studies, imaging, and, if warranted, consultation with specialists.  While the copay and coinsurance will be significantly higher, you are paying for access to a one-stop solution — and one that doesn’t require an appointment and is available 24/7. And if you call 911, you get a literal house call from a group of trained mid-level providers who show up with diagnostic equipment and medications that most primary care physicians don’t have in their offices — along with a ride to the above referenced emergency room where the majority of your medical needs can begin to be addressed.

Is emergency medicine, both in-hospital and prehospital, over utilized?  Absolutely?  What’s the solution?  I honestly don’t know.  I do know what doesn’t work — and that’s emergency medicine providers complaining about overutilization of emergency services.  In all likelihood, there’s probably no one solution. From the standpoint of business and economics, I’ve never known a successful business model based on telling people they don’t need your services and turning them away. Emergency medicine, both EMS and emergency departments, need to embrace their role as providers of unscheduled medicine to the masses.  Likewise, primary care, in order to remain relevant, needs to understand that not every patient’s needs can be scheduled two weeks from next Thursday and only during regular office hours. The problem is not an unequal or even inefficient model of healthcare delivery.  The problem is and remains a healthcare delivery system that is not meeting the schedule and demands of modern society.