Rural EMS and the Rural Hospital Crisis.

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.

Election Night (Not what you think)

Election Night brings out the worst in many of us. In large part because of the 24 hour news cycle amplified by social media, we get way too invested in politics and sometimes let our mouth overload our rear. (Pro-tip for those of us who love politics and love discussing it, private groups are the way to go on Facebook.)

I saw some of the worst behavior come from my fellow members of the Bar. Many attorneys I know were posting things that I wouldn’t have expected from dispassionate professionals.  The comments (and they were from both sides of the political aisle) ranged from sour grapes, veiled passive-aggressive statements, or out and out statements that they’d be unfriending people. (Another pro-tip here.  I do know some of these people and it speaks volumes as to their professionalism and whether I might believe they have the temperament to handle a case I might refer their way.)

Late last night, a post started making its way through EMS social media showing a paramedic saying (in part), “I’ll start asking if you are a trump (sic) supporter – if you are, y’all will die in my ambulance.”  The response from EMS was swift and gave me a great deal of hope for our emerging profession.  Everyone denounced it.  Whether you wanted to “make America great again” or identified as a democratic socialist, everyone agreed that this sentiment had no place in EMS.  And they spoke up.  Not only did they speak up, they made a point to notify this guy’s employer and the various licensing entities that they didn’t want him in our profession.  At least one employer terminated their relationship with him by morning and at least one licensing agency is aware of his temperament to practice as a paramedic.

Regardless of whether the gentleman deserves to remain employed or certified as a paramedic, our profession spoke with one voice and said that we won’t tolerate such a mindset. And my other profession, the profession of law, has become so politicized and activist (on both sides) that we have, at least in some part, lost track of what we’re supposed to be doing, namely zealously representing our clients and providing them with sober counsel.

Last night, EMS stepped up and took a stand for our profession.  And for a change, we did it better than the lawyers.  Pardon me while I brag on being a paramedic. We’ve beat the other professionals at being professional and separating the personal from the professional.

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

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.

Are You Really Surprised?

This morning, I happened to read an article where a Senator was grandstanding about the supposed opiate abuse epidemic.  He was blaming the epidemic on everyone.  Doctors, the “evil” pharmaceutical industry, and even the DEA for not “doing something.”  Because whenever something is in the news, politicians want to “do something!”

I don’t deny that we have an epidemic of opiate abuse.  But at the most fundamental level, there is someone to blame — namely, politicians.  Our politicians have created government involvement in healthcare. (Whether that’s a good thing or a bad thing is another debate for another time.)  With government involvement comes the need to “measure” how effective the government interventions are.  And as we’ve all found when the government studies medicine, they like things that are easy to measure and sound good.   In EMS, that’s usually cardiac arrest survival — because dead or not dead is easy to measure and by golly, we don’t want dead people.

So, the government decided that “pain” was something worth measuring and studying for Medicare and Medicaid.  And then, the various accrediting bodies jumped on board because the government had already decided that pain management was a “good thing” and therefore measuring it for accreditation purposes was also a “good thing.” So, along came the messages.  Pain scale charts everywhere.  Providers being judged for pain management.  Providers being told that the goal is to get the pain to a zero on a zero to ten schedule.

But the reality kicks in.  In most acute settings (including EMS), we have limited pain management tools — mostly opiates.  And for the average person, pain is an emergency.  And I’ve already mentioned how hard it can be to get in to see a primary care provider and the inevitable referrals to specialists, labs, and imaging for all but the most minor complaints.  In short, if you’re in pain, you have two choices — be in pain until your doctor can see you and then get an opinion as to what’s wrong or seek immediate care and get opiates.

So, here we are.  People are rational and usually want relief now.  So, the tool of choice for acute pain management remains opiates. And people are now expecting their pain to be managed and they’ve almost come to expect that the relief will come in the form of an opiate. We’re now at the point where patients feel they have right to opiates for pain management.  Is it any wonder that we’ve created addicts?

And at the same time that CMS and the healthcare accreditation world demand that we “DO SOMETHING” about pain, the DEA and many state medical boards have differing opinions.  The current opiate “crisis” has led to a concern about overprescribing, which, in many cases, is rightfully justified. Especially in Texas, we’ve had a crisis with “pill mills” writing narcotic prescriptions way too easily for virtually no medical reason.  Those providers can and should be sanctioned.  But the DEA and the various state medical boards have also created a climate of fear where physicians feel as if their professional prerogative to treat patients is questioned, thus causing most chronic pain patients to be referred to pain management clinics, where again, there’s a wait to be seen, thus sending patients back to the acute care world and/or street drugs.

And as for the DEA, let’s not forget their unusual interpretations of the various controlled substances laws. Because most laws (including controlled substances laws) aren’t written to consider EMS, we’ve had some bizarre implementations of the laws by DEA in particular.  There are several DEA regional offices that have determined that EMS has no authority to administer any controlled substances (pain management and sedation).  Others have held that each ambulance and station (or posting location in system status management) has to be licensed as a facility by the DEA.  These competing interpretations have reached the point there’s legislation pending before Congress to clarify EMS providers’ authority to administer controlled substances.

And in the EMS setting, let’s not even discuss that the only pain management option we have in most systems is an opiate.  Opiates aren’t great for chronic pain or mild pain, but if the only tool you have is a hammer, everything starts to look like a nail.

I’ve been a lawyer in government practice for over twelve years now.  I don’t expect that you can get various government agencies to all get along or even use the same playbook.  But what I have come to expect is that if you get government involved in healthcare, you’re going to have some unintended consequences. The only thing you can consistently expect from government interfering in the physician (or nurse or medic) relationship with a patient is that there will be consequences.  And said consequences will be unexpected.  More often than not, they may even be worse than the problem they were addressing.

Google Let Me Down.

The following is an email that I sent to Google in response to them choosing artist/activist Yuri Kochiyama for today’s Google Doodle on the main Google page.

I realize that Google Doodles are sometimes meant to cause us to think.  That’s a good thing.   But today’s Google Doodle honoring Yuri Kochiyama was way too much.  I “Googled” her and found this in Wikipedia:

In response to the United States’ actions following the September 11 attacks in 2001, Kochiyama stated that “it’s important we all understand that the main terrorist and the main enemy of the world’s people is the U.S. government” and that “the goal of the war [on terrorism] is more than just getting oil and fuel. The United States is intent on taking over the world.”

While the United States has certainly made mistakes and there are certainly different views about our role in the world, I consider honoring this “activist” to be a grave dishonor and a slap in the face to those who died on 9/11, first responders, and those who serve in our United States armed forces.

Over the last two weeks, there has been extensive media coverage about an anti-conservative bias in the tech world. While I had been somewhat skeptical of this, your decision to “honor” this far-left, anti-American activist is certainly evidence of at least a cognitive disconnect with many Americans, especially those who hold conservative or libertarian values.

To me, Google is a source of information.  I expect an information source to be an honest broker of such information or, at the very least, to disclose its biases.  Today, Google let me down.  And that’s something that’s let me down.

Very truly yours,

Wes Ogilvie

I could go on and on here, but suffice it to say that I think it’s bad business to take an unnecessary political stand that pokes many of your customers right in the eye. Rather than an attempt to be hip, edgy, or thought-provoking, this decision shows the disdain that many in the cultural left have for anyone in “flyover country.” These tech hipsters share their progressive views where the tech industry gets government subsidies while wearing a Che Guevara t-shirt and “Feeling the Bern.” It always strikes me that many of the people who are the loudest about the wrongs in America are among those who benefit the most from what makes America great — namely free enterprise supported by the values enshrined in our United States Constitution.

In summation, you’d never have a Google, Apple, Facebook, Dell, the New York Times, or even the movie industry in anyplace but America.  And as the late great Merle Haggard sang, “If you don’t love it, leave it.  Let this song I’m singing be your warning.”

This is a collaborative post by Too Old To Work, Too Young To Retire (TOTWTYTR) and me. It started from an email exchange and then we decided write a post that will appear on both blogs. I’m not sure exactly how this will work out, but it’s worth a try.
TOTWTYTR: I will say that I’m not sure how much Presidential election blogging I will do this time around. Neither of the “presumptive” candidates are ideal by any definition of the word. One is a brash entrepreneur and reality TV show host with no political experience. The other is the epitome of the political insider. Who also happens to have little in the way of achievement that isn’t tied to her former President husband. Trump is (or was) hated by the GOP establishment, while Clinton is the darling of the Donkey set.
Those are my preliminary thoughts outside of the collaborative portion of the post. The parts in regular fonts are from the original email from The Ambulance Chaser. My comments are in red interspersed.
ME: So, since we’re among friends and for the most part, relatively like-minded
ones at that, I figure I’ll share my insights as to how we’ve ended up with
Donald Trump as the presumptive Republican nominee.
Let me first say that, in the words of Marc Antony, I come to bury Trump,
not praise him.  I cast my vote for Cruz not out of support
of him, but at least knowing who he is and what he stands for.   Like some
of us here, I too share the disgust at the Republican Party’s current
fascination with bedroom and bathroom habits.  It’s unseemly,
narrow-minded, and especially hypocritical coming from a party that
supposedly is the champion of limited government.
TOTWTYTR: Which is the common perception, but the Democrats seem far more interested of
late in peoples’ sex lives and bathroom habits. After all, it’s they that are proposing “affirmative consent” laws
on campuses and trying to change the public bathroom habits of the American public.
Trump has for the most part totally ignored those issues and the pressure to discuss them. Wise move.
My major complaint with the Republican Party, which I share with you, is that they aren’t acting like conservatives.
This despite the fact that most Americans are politically center-right, not left.
ME: So, how’d we get to Trump?  Well, for one thing, I do think that social
conservatism has a limited appeal.  There’s only so many voters out there
for whom homosexuality, abortion, and school prayer are their core,
fundamental issues.  Bluntly, if it was me, I wouldn’t even make an effort
to appeal to them.  And by and large, Trump really hasn’t.
TOTWTYTR: See? We agree.
ME: What has Trump done?  He’s appealed to blue collar Reagan Democrats.  The
comments about foreign trade and “making America great again” appeal to
blue collar, Rust Belt voters.  For all of the talk about the Republicans
being “politically incorrect,” the Republicans really aren’t all that
willing to offend or speak painful truths.  Trump has said what many people
are afraid to say in “polite company” about immigration and Islamic
terrorism. And in that “everyman” appeal, he scores more points with
voters.  While I don’t have the statistical analysis, I’d hazard a guess
that Trump is doing especially well with independent and previously
unengaged voters.
TOTWTYTR: This is one point on which we disagree.
Trump is drawing support from broad segments of the population. For the
most part it’s people who are fed up with the establishments of both
parties. That was part of the appeal of Ted Cruz and is a large part of
the appeal of Bernie Sanders.
My sister, who is at least on the surface a liberal Democrat, is a self
described “Bernie Girl”. I’m not sure what his appeal to her is, because
chances are she’ll be negatively impacted by his communist financial
My son has a MBA and is a Trump supporter. Trump is hugely popular in
the southern state in which he lives. My daughter in law says that if it comes
down to Trump vs Hillary, she’ll stay home. Which is okay, because
that’s in effect a vote for Trump. She is pretty conservative. No
college, but she’s a sharp young women.
Mrs. EMS Artifact didn’t like Cruz, but likes Trump. If anything, she is far more
conservative than people think I am. She can’t stand Hillary or Bernie, especially Hillary.
My friend Peg, a former Canadian and former left leaning Democrat, hates
Obama, Hillary, and Bernie. She likes Trump, but not Cruz.
Women not liking Cruz seems to be a trend, at least in my not very scientific polling.
I have several friends who are life long Republicans who like Trump.
They’re tired of the GOP establishment bending over for the Democrats.
They want conservative fiscal policies, don’t care about social issues either way, do care about immigration.
I could go on and on in this vein, but I think the point is clear.
ME: In all fairness, Trump is remarkably naive on foreign and defense affairs.
His comments about making NATO, South Korea, and Japan pay for more of
their defense are short-sighted and, if enacted, could well lead to the USA
losing leverage there and those nations asserting a more independent
foreign policy that might not align with US interests.  As for his domestic
policies, he makes vague promises that make for great soundbites.  For
those that mock and dismiss him, I’ll note that Obama got elected on vague
promises of “hope and change.” That worked for enough voters.  It might
just well for Trump.
TOTWTYTR: I don’t know if Trump is a conservative or not. I think he’s more of a
populist than anything else. If he wins, I hop he’ll make good choices
for his cabinet, national security adviser, head of the CIA, etc… The
big question with Trump is federal judges, especially SCOTUS.
This is my biggest question mark about Trump. What will he do if he wins? Will he govern from the center,
the right, or the left? Or a mix?
Of course he won’t be the first candidate that was elected with the electorate not knowing where he
stands on some crucial issues.
Of course, I could be wrong about that. He might pick judges that are more liberal than would Hillary.
I doubt it, though.
Obama has proposed that our allies pick up more
of the funding for NATO and their own defense. Which is one reason we
don’t have nearly as many allies as we did a few years ago.
Japan has increased defense spending, as have other of our allies. They have
zero faith in Obama fulfilling any of the US obligations to defend them if it
comes to that. T: aiwan and South Korea share that, as do allied countries in Europe.
Our so called allies in the Middle East are also very concerned about this election.
I’m not suggesting that we pay for all of our allies defense forces, but there is value
in having a strong military of our own. Helping other nations is part of that, but they are going
to have to increase their commitment to defending themselves. Especially Europe, which I expect
is once again going to be defending the gates of Vienna from the Islamic hoards. Or maybe London,
Paris and Berlin.
ME: Both parties are to blame for the Trump phenomenon. The Republicans talk a tough game,
especially on immigration, and routinely fail to deliver — primarily because many of
their large business supporters depend on immigration. All the Republicans have delivered
during the Obama administration, with congressional majorities for six of eight years, are
press releases, showboating, grandstanding, and pandering to a small fringe of evangelical
voters who wouldn’t vote for the Democrats anyway. The Democrats have delivered more government
entitlements, more wealth transfer, a near Communist fascination with class envy, and a naked,
brazen attempt to appeal to every identity group out there.
TOTWTYTR: Trump is expressing the disgust of people in both parties with the
status quo. You’ll notice that no one has asked Obama to go out and
campaign with or for them. For good reason, President Jug Ears is not
particularly popular.
ME: The media?  Well, they have some fault too. They bemoan the lack of
substance in politics, yet they engage in “gotcha” journalism designed to
dig up past mistakes and foibles, thus eliminating anyone except those
bland candidates who, since fifth grade, have strove to avoid anything
controversial or embarrassing.  They’ve turned politics into a horserace
and a reality show.  In fact, “Who Wants To Be President” might well turn
out a better candidate than the primary process has this year.
The media is in the bag for the Democrats. Very few people in the media
identify as Republicans and even a casual perusal of the news will show
that the main stream media does all it can to cover for Obama and
Hillary. I expect that the attacks on Trump in the MSM will intensify
now that he’s the presumptive nominee.
The modern left and the modern right are both incredibly out of touch with
most Americans.  Both parties engage in “crony capitalism” where free
enterprise is a myth.  Rather, big business plays both parties for
subsidies.  The Republicans fund “economic development” and grant subsidies
to corporate agriculture.  Meanwhile the Democrats will fund “green energy”
and want to address economic justice by giving money to people with bad
credit and build nice things in areas where people are rioting.
So, when modern liberalism helps us “feel the Bern” in our “safe spaces”
and modern conservatism is worried about the bathroom at Target, yet fails
to seriously address terrorism or an economy that works for what the modern
left and the Wall Street crowd calls “flyover country,” we can look in the
mirror and realize that the sad state of American politics and the American
media have given us Donald Trump.  We’ve ended up with a self-funded
billionaire who, by his sheer wealth, is perceived to not have to pander to
any donors and says the first thing on his mind.  America, meet your
reality show presidential candidate.
TOTWTYTR: Thus, we have the rise of a neo populist candidate that has been remarkably non specific
about what he actually plans to do to “Make America Great Again”.
Obama gave rise to Trump’s model of campaigning. He too ran as a neo populist who was remarkably
non specific about what he would actually do. We’ve had eight years of fundamental transformation and
it appears that much of the voting public is tired of that.
I’m not sure if the public knows that they want in the next President, but they have made it very clear what they
DON’T want.

You Get What You Pay For

In Texas, we have a strong tradition of limited government.  In particular, we limit the role of county government.  In most counties, county government provides law enforcement, jails, courts, and roads.  Because of the limits placed on county government by the Texas Constitution as well as the limited source of funds available to county government (primarily property tax revenues), the majority of county governments in Texas do not directly provide fire or EMS services.  In response to the need to fund fire and EMS services for smaller communities and/or unincorporated areas of the county, the Texas Legislature authorizes the creation of Emergency Services Districts (ESDs).   ESDs have the authority to levy a property tax to provide fire and/or EMS protection within their boundaries. That tax is up to ten cents per one hundred dollars of property value.

North Hays County ESD #1 is the Emergency Services District that serves Dripping Springs and much of the rest of northwestern Hays County.  They currently tax their property at a rate of 2.52 cents per one hundred dollars of property value.  They are holding an election on May 7 to raise the tax rate to a maximum of seven cents per hundred dollars of property value to continue funding EMS in their district.  Currently, San Marcos/Hays County EMS is their contracted EMS provider and, like many EMS systems, faces increasing call volume as well as increasing costs of providing EMS in the district.  (Disclosure: I formerly worked as a part-time medic for San Marcos/Hays County EMS. I have also responded with San Marcos/Hays County EMS on mutual aid with another EMS service in the area.)

Enter the local state representative in the area — a man named Jason Isaac. Mr. Isaac has come out publicly against the tax increase and is pandering to a reactionary anti-tax element of a conservative electorate.  Heck, I’m pretty conservative.  Those that know me have described me as a fiscal conservative, socially libertarian, and a neo-conservative hawk on foreign policy.  I’m no Bernie Sanders here.

If Mr. Isaac is truly concerned about the actions of the ESD, he would know that the Texas Department of Agriculture has information about the formation and operation of ESDs.  But it’s easier to put out posts on social media addressing an issue where the accountability lies with local government.  I thought that Texas conservatives favored local control and local solutions for local problems?

But there are some very legitimate roles for government to play, particularly local government. One expectation that all of us have, save for a few anarchists, is for our 911 calls to be answered and for help to come.  Better yet, we expect competent providers to deliver compassionate and clinically appropriate emergency medical care.  San Marcos/Hays County EMS has delivered that care to Hays County for years, including the residents of North Hays County ESD #1.  I’m standing for quality EMS, not sound-bites designed to appeal to fears about property taxes.

Clickbait for you. Frustration for me.

Right now, the EMS social media is abuzz with a piece of so-called religious rights legislation that’s passed the Michigan House of Representatives.  In short, the legislation allows for a person to claim a religious exemption from other laws that infringe upon their religious rights.  Currently, legislation such as this is most commonly championed by Christian social conservatives as an attempt to nullify local and state gay rights provisions.  Our “friends” at EMS1 are headlining this as “Will Michigan allow EMS providers to withhold care based on the patient’s sexuality?”

Here’s my take as an EMS provider, attorney, and someone who’s analyzed state legislation for over a dozen years.  Oh, and also as someone who completely supports the rights of gays and lesbians, including the right to marry.  This bill doesn’t impact EMS one bit.  Not one iota at all.  Doesn’t even mention EMS. I am not YOUR lawyer (although, for the right retainer and hourly rate, that COULD change…), but I can’t see how this proposed piece of legislation changes the duty to respond and the duty to act for EMS (or the fire department or police either).

Also, the bill has only passed through the Michigan House of Representatives and still has to make it past the Michigan Senate and get the signature of the Governor.  As I’ve said before, the legislative process is designed to kill legislation, not pass it.  The chances of a bill getting becoming law are slightly better than my getting a lucrative basketball contract, but probably not as good as your next EMS shift not getting to transport a non-acute patient.

I blame two parties for this kerfuffle and misinformation.  One, somewhere out there, there’s probably a well-meaning and sincere gay rights activist who took the conclusions of this legislation well past the logical extreme.  Second, the lemmings of EMS social media AND the EMS websites blindly posted this without any research, whether out of a lack of legal understanding, believing in a specific agenda, or just trying to drive up clicks.

I’m going to do something I only do occasionally and only when I’m really peeved. I’m calling a publication out by name.  EMS1 — You guys should know better.

As the great American President Abraham Lincoln once said, “Don’t believe everything you read on the internet.”

I am not a hero

In my “real” job, I’m sure as heck not a hero.  Reviewing contracts just doesn’t save a lot of lives.

When I’m at my “fun” job on the ambulance, it’s not heroism either.  It’s doing something I’m passionate about.  It’s the pride, honor, integrity, and dare I say, the compassion of providing medical care to people in the worst moments.  (Let’s face it, even if we consider it “BS,” it’s still the worst thing in our patient’s day.)  I walk into houses, businesses, and the street and see humanity at its worst.

I’m hanging out at the Texas EMS Conference this week, learning new things, renewing friendships, and making new friends.  Watching a British paramedic experiencing Texas for the first time is rather funny at times.  Driving through the Fort Worth Stockyards listening to George Strait while you explain the history of our country, our state, and the “Old West” is a perfect way to remind yourself of how special these moments are.  EMS, fire, law enforcement, and emergency medicine creates a special bond and kinship between all of us.

But allow me to digress here into the really serious current events of the day.  Ferguson, Missouri.  I’ve had a few friends who aren’t in public safety or medicine post some pretty snarky comments on Facebook about the grand jury decision, Officer Darren Wilson, and/or law enforcement in general. I won’t hector or lecture you.  All I ask is that you try to be as compassionate to your public servants as you are to the thug culture, the “oppressed” who aren’t really oppressed, the criminal underclass, and the looters.  Take it from someone who sees more than Instagram shots of the Mike Browns and Leslie Cochrans of the world — crime, homelessness, and the drug culture aren’t hip, cool, or funny.  They’re a one-way ticket to self-destruction.

You have a right to those opinions.  The “uncool” people that you mock protect your rights to be hip, liberal, and oh so cool. Me?  I have the right to unfriend you.

Thanks for listening.  I’ll try to be funnier in the next blog.


Hey there, it’s The Ambulance Chaser.

Recently, a friend of mine asked why he should renew his NAEMT membership.  I had to think for a minute.  Then I thought for several more minutes. Finally, I told him I maintain my NAEMT membership because I’m affiliate faculty for one of your continuing education programs and because membership provides me a significant discount on EMS Expo (Every other year in Las Vegas – yes please!).   Another person mentioned the 5.11 clothing discount.

What nobody mentioned was NAEMT’s advocacy for the profession.  Why?  Rightly or wrongly, it’s because a lot of us in the field see NAEMT and its leadership as a self-perpetuating good old boys club advocating for its pet causes.

Some of you who know me away from my blog know that I’ve been in state government for over ten years as an attorney and that I’ve previously been legislative staff here in the Lone Star State and have even worked in political campaigns.   When have I seen or met with a representative from NAEMT or any state affiliate (by the way, Texas no longer has a state organization affiliated with NAEMT)?  NEVER.

What do I see from NAEMT for advocacy?  Ham-handed attempts at influencing Congress.  The EMS Field Bill is a useless attempt at finding another source of money for certain EMS agencies that already excel at writing grant applications.  EMS on the Hill Day is, while well-meaning, just another opportunity for certain EMS leaders to wear full dress uniforms that look like a cross between the Knights of Columbus, Captain Crunch, and a Turkish admiral.

Right now, there’s a discussion on the Texas EMS email list about a Texas Board of Nursing administrative rule that’s been interpreted and applied so as to prevent EMS providers from functioning at their certification level in the emergency room.  How does this happen?  Quite simply.  The nursing profession is organized and knows how to get things done politically.  Our supposed “voice for our profession” is way too quiet in the Texas state capitol.  I’m willing to bet you that the other 49 state capitols aren’t being visited by NAEMT either.

So, NAEMT, here’s the deal.  I’m going to keep my membership up.  I want to go to Vegas cheaper (who doesn’t?). I want my continuing education classes, although it’s a damned shame that we have to rely on so much continuing education to make up for the gaps in our initial education.  And yes, I occasionally want some discounted clothing.

But since I’m a member, I’m going to continue to speak out.  And I’m going to keep asking when you’re going to step up for our profession in a meaningful way.  Self congratulatory photos and press releases mentioning the same old names just aren’t going to cut it forever.