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.

Being a Sheepdog

A good friend of mine who’s a non-practicing paramedic and currently serves as a law enforcement officer out in the Texas Hill Country had a good post on Facebook about the current divide in this country and how it’s also manifesting itself in the divide between law enforcement and the public they serve.

I’d say the gap exists, not just between law enforcement and the community, but between public servants (police, fire, military, and EMS) and the community.  There’s a lot of reasons, I’m sure, but allow me to throw some thoughts out there.

For better or worse, and certainly without ill intentions, we have created a lot of those barriers.  We’ve hidden behind artificially created barriers between “us” and the public we serve.  We cite “homeland security,” “officer safety,” and “HIPAA” as reasons why we no longer engage with the public or create barriers to such engagement.

Several years ago, while on vacation in an unnamed large city known for legalized gambling, buffets, and neon signs, I stopped by their central fire station to get some photos and maybe meet some firefighters and/or medics.   The garage bay doors were closed and there wasn’t even a doorbell to ring.  I walked around to another door and there was a phone to pick up.  When I explained that I was a visiting medic from Texas, I was promptly told that their station wasn’t open to visitors or the public.

Combine that with some communities encrypting all public safety communications (granted, I have ZERO problem with encrypting sensitive channels like SWAT, narcotics, surveillance, etc.) and eliminating ride-alongs, and you’ve created an environment where a communications barrier exists — and where rumor and conspiracy theories can flourish.

Yes, those of us who are public servants are the sheepdogs who protect the sheep.  If anything, that means even MORE of an obligation to be amongst the sheep.

My advice: be approachable.  Let’s be the ones who remind the public that we’re here for them.  Otherwise, as we’ve seen this week near St. Louis, those who reflexively dislike us will have ample opportunity to spread their message.  For better or worse, we live in a constitutional republic and we are servants of the public.  It behooves us to gain and maintain the public’s trust.  One can practice “officer safety,” “scene safety,” or “situational awareness” without coming across as a member of an occupying army.  Take off the wrap-around shades, interact with the public, and show a kid (or even, gasp, an adult) your vehicle.  It’ll keep you safer in the long run.

Ok, rant over, y’all.

On Liability

As an attorney and a paramedic, I’ve definitely got opinions on medical malpractice and liability.  As some of my devoted minions (well, all two of you outside of family), I’ve experienced my own issues with healthcare liability, not all of which I’ve blogged about.

First, my legal profession deserves a huge chunk of blame for this.  We’ve convinced the public, either deliberately or by omission, that a bad outcome automatically equates to malpractice.  This just isn’t true.  No one in the medical world is able to work miracles or reverse irreversible processes.  We will all die of something eventually and sometimes, even in the best settings, there is nothing that can be done for that.

However, the medical world bears some fault as well.  The medical world regularly fails to understand how the legal system works and as such, probably makes things worse.   The things I see most often are administrators and risk managers who try to mitigate risk down to zero.  As such, good medicines, good interventions, and good clinical judgment get banished in the name of “patient protection.”  The acceptable/tolerable risk to the healthcare liability watchdogs, accrediting bodies, and risk managers becomes ZERO.  As but a simple example of that, look how Phenergan (promethazine) has greatly been displaced as an anti-emetic in the emergency and prehospital settings by Zofran (ondasterone) because of the concerns about vascular damage.   Yes, the danger exists, but there are steps to mitigate the risk.  However, for the people whose livelihood is made by “protecting” clinicians from the lawsuit bogeyman, zero risk is tolerable.  So, when you have a patient who’s vomiting up their Zofran orally-dissolving tablets, thank risk management.  <GRIN>

Additionally, the risk management types like to hide transparency or accountability behind the fear of litigation.  As such, we end up with “peer reviews” where medical misadventures are hid behind laws that shield the providers from accountability.  These inspire a belief amongst laypersons that the professional community shields its own.  Even if the provider receives discipline or remediation after a peer review, it’s considered confidential by law (at least in Texas). In my opinion, this limits transparency and accountability and enhances the “coverup” feeling that patients and/or their families sometimes feel.

Many people who’ve experienced a bad outcome come to lawyers in the hopes that the bad outcome can be explained.  Granted, some come for the litigation jackpot, but there’s also a great number of people who seek legal counsel because of an honest desire to find out what happened.

My solutions are simple.  It’s getting them into place that would be the hard part.

Step 1: Accountability and transparency.  First, any explanations or apologies provided by healthcare providers should be excluded, as a matter of law, from serving as evidence of liability.  Second, peer review confidentiality should be waived to the extent in the event that a provider does receive remediation or a loss of privileges that the complaining party is informed.  However, this waiver still should not be admissible for purposes of establishing liability.

Step 2: Judges should start dismissing frivolous claims.  Period.  This alone would go a great deal toward fixing the frivolous lawsuit issue.  Judges already have the power, but many are afraid to use it because campaign contributions often come from the same lawyers who file the suits.  For the plaintiffs’ lawyers out there, this has got to be preferable to tort reform statutes that limit access to the courts.

Step 3: Here’s my solution to the litigation lottery jackpot.  I’d establish healthcare liability courts in addition to the current court system.  If you want to file your suit in the “regular” courts and try to persuade twelve people who couldn’t get out of jury duty of your righteous anger, then by all means file in “regular” court.  Just understand that damages will be capped at a certain amount and that you won’t get a windfall for “pain and suffering” or other unquantifiable claims.  Healthcare courts would exist without any damage caps.  Here are the two catches.  First, no juries.  Your case will be heard and decided by a judge with expertise in medical liability.  Second, the court can also appoint its own expert to examine the facts of the case and issue a report to the judge. To me, this would lessen the influence of the “hired gun” expert witnesses used by both plaintiffs and defendants.

The pendulum of medical liability constantly swings back and forth between two extremes.  I believe that both extremes fail to satisfy justice.  The legal community needs to understand that bad outcomes aren’t automatically to be associated with wrongdoing. And the medical community owes it to the public it serves to accept responsibility and accountability when something does go wrong.  It goes back to preschool — there’s a great deal of healing power in a simple, sincere apology.  “I’m sorry” goes a long way.

Progressive tension

Most of the time, I try to stay out of politics here, except for EMS politics.  Today, I digress into international politics and religion.  Why?  Because I’m calling out hypocrisy.  If you don’t like my views, that’s ok too.   Google “cute kitten pictures” and come back when I’m blogging on a medical issue again.

Today, I’m calling out the progressive community.  On some issues, I agree with them, especially regarding individual freedoms.   Want to open up a casino that performs gay marriages and has a women’s health clinic that additionally distributes marijuana on site?  Go for it!  Having said that, don’t expect me to subsidize it with my tax money.

But here’s the hypocrisy of the modern left.  By and large, the modern left embraces cultural relativism and multiculturalism.  That’s well and good to be tolerant.  But tolerance is a Western value.  A lot of other cultures don’t embrace tolerance.  Tolerance to them is that you submit to their ideologies and beliefs.

Over the past month, terrorists have kidnapped 200 Nigerian schoolgirls for getting a Western education, a Sudanese woman has been condemned to death for abandoning the faith of her father to become Christian, and several honor killings have been publicized in Pakistan.  George Takei has publicized the plight of the woman in Sudan and no less than the First Lady of the United States, Michelle Obama has tweeted “#BringBackOurGirls” in response to the Nigerian kidnappings.  (Personally, I think a visit from SEAL Team 6 and/or the British Special Air Service would go a long ways toward bringing those girls back.)

For years, mostly conservatives and secular European libertarians have been pointing out that Islam does not always share our Western values, in particular many of the values that the progressive left claims to value such as freedom of religion, secular government, and women’s rights. What did the Left tell those Cassandras who warned us of the intolerance of politicized, radicalized Islam?  Why, Islamophobia of course.

Of course, the minute the Nigerian girls were kidnapped by an Islamic terrorist group whose name literally means “Western education is wrong,” the progressive movement had to say something.  After all, feminism is a core tenet of the modern left.  And at that point, the warning and condemnations came out.  Why, Jay Leno’s wife even came out against sharia (Islamic) law.  Previously, the left described warnings against sharia as Islamophobia from the Tea Party and chuckled a smug, knowing laugh.  (You know, think Bill Maher, Stephen Colbert, or Jon Stewart.)

Tolerance is a virtue (as the old saw goes), but tolerating and granting moral equivalence to a culture and belief system that is diametrically and violently opposed to your own ceases to become tolerance.  Rather, it becomes a suicide pact.   To my liberal friends who wish to appease the barbarians at the gate, don’t think that the wolf won’t eat you.  The wolf may just eat you last.

Activism masquerading as medicine

As most of you have no doubt figured out by now, I tend towards the right of center, fluctuating between conservatism on economics, crime, and foreign policy and more on the libertarian side of social issues.  (Want an abortion, marry your same-sex partner, or smoke pot?  I don’t care.  Just don’t ask me to subsidize it.)

I don’t care what your politics are, personally.  I have friends who make Pat Robertson seem like an atheist and friends who make Barack Obama look like the founding member of the Tea Party.

What I do care about is when you use a position of authority to claim to be an unbiased authority — or when you use your position as my physician to promote a political or social agenda — regardless of the cause.

As of late, I’ve seen physicians advocate for gun control, against extraordinary rendition of terrorism suspects, for air pollution controls (in the name of prevention of children’s asthma, no less!) and against fast food.

What I’m unclear about is where the practice of medicine ends and where the political advocacy begins.  From the looks of it, many physicians are too.  Years ago, public health meant epidemiology and disease prevention.  Now, the modern liberal nanny state has morphed public health into a form of political activism.   I’ve got no problem with advocating for your agenda, just don’t say that your position is a matter of medicine.  Because if doctors can make law by virtue of their medical education, it’s a short jump before lawyers are able to make medical policy by virtue of their legal education. And we all know how well that works….

On Politics

I rarely get political here for two reasons.  First, my political beliefs are all over the place.  I’m overall somewhere between conservative and libertarian on most issues.  When it comes to foreign policy, I often make Dick Cheney look like George McGovern.  But I also think that Elizabeth Warren and Bernie Sanders may be right about the Wall Street crowd being bad for our economy long-term.   Second, most of y’all are here to read my EMS brilliance, or what passes for it.   However, I ask your indulgence as I go off on a rant against a trend in American politics that I don’t like.

In short, if your ideas or agenda can’t win in the political arena, that should tell you something.  You’re not winning.  Either accept the defeat graciously or you repackage and resell your ideas to the public.

However, instead, we find both sides, but primarily the modern Left, resorting to enacting public policy through litigation and/or the “public health” arena.

Texas and several other states have been the subject of litigation by anti-death penalty activists seeking to expose the suppliers of execution drugs.  While they couch their arguments in terms of the public’s right to know, the reality is that they are using the courts and the legal process to try and enact a political agenda that hasn’t won in the legislative process.  As an attorney, I try to view the courts as the means to resolve a dispute between two parties rather than as a way to enact social changes.  If you want to enact social changes, run for office on your platform and see how it stands with the voters.

And let’s look at “public health.”  Years ago, I imagined the word of public health as focusing on epidemiology and disease prevention.  Now, the way to control people’s lifestyle has become through the “public health” process.  Want to ban trans fats?  Simple.  Call it a public health crisis.  Want to ban big Cokes?  Call it a public health crisis.  (And yes, the Texan in me calls every soft drink a “Coke.”  Welcome to Texas, the only state you’ll be asked what kind of Coke you want and it’s ok to answer with, “I’ll have a Sprite, thanks.”)  Want to ban guns?  Call it a public health crisis.  To me, the real public health crisis is how many parents ignore science in favor of Jenny McCarthy and refuse to vaccinate their children.

What we really have here is a public policy crisis where those people who want to enact unpopular agendas resort to an alternative way to enact them.  And on that note, I return you to your regularly scheduled internet agenda of cat memes.  Thanks for listening, y’all.

Two quick observations….

About EMS legal/political issues.

1) Most EMS legal issues aren’t actually analyzed by an attorney.  Rather, they’re analyzed by a person with no legal training who is making an exceptionally uneducated guess about what they think a lawyer might tell them.  You know, it’d be like the random attorney reading a 12-lead with no education.

2) People seem to think that if a definition in the law is changed to make EMS an “essential, ” “emergency, ” or some other word attached to service, then the “powers that be” will HAVE to fund EMS.  Anytime anyone says that a definitional change to the law will ensure EMS funding, it’s obvious that they don’t understand law, politics, public policy, economics, or the political process.  If you believe a change in law will fund EMS, look at the amount of lawsuits over the equity (actually, the amount) of public school funding.  This kind of simplistic thinking shows why EMS still isn’t invited to the “big kids’ table.”  And EMS’s simplistic fascination with the next big funding bill is shown in the mindless support of the so-called “Field EMS Bill” that NAEMT hawks as a snake-oil panacea to every EMS problem.  After all, we all know that endless streams of Federal money fixes every problem.

About unions

Most of y’all who know me in real life know me to be somewhere right of center, somewhere around the level of being a practical minded libertarian on most issues and a raging hawk on foreign policy and national security.   So, this may come as a surprise to you.   I think unions are a necessary check and balance in the workplace.  My problem with unions is that they’ve been getting it wrong for so long and this getting it wrong is causing some real problems.

I live in an area of Texas where the local municipal police union has a large role in city politics.  The fire union to a lesser extent.  And the local third-service municipal EMS service recently obtained civil service protection, first by convincing the Texas Legislature to change state civil service law to cover third-service EMS, then convincing the voters of this unnamed “progressive” city along the Colorado River to approve said civil service protections.

So, what have the police and EMS union both done with their state civil service protections under Chapter 143 of the Texas Local Government Code?  Why they agreed to sit down at the table with city management and fritter away civil service due process protections for discipline, promotions, and hiring in return for some changes to pay rates and cost of living raises and, in the case of the police, some increased pension benefits.  The city sees giving away a few million bucks over the life of a union contract as chump change in return for the ability to return to a de facto at will employment status, the ability to play politics with the hiring process, and the ability to manipulate the selection of middle and upper level supervision/management.

The unions point to their pay raises and the political pull they have locally due to donating campaign cash to (usually) sure winners.   Sadly, pay is only part of what a union is supposed to advocate for.  When said unions don’t campaign equally aggressively for workplace conditions (call volume means a need for more medics/cops/firefighters, y’all) and due process for employee hiring, promotion, and discipline, they’re selling their members out even worse than they might be without a union.  Believing you’re protected is probably worse than when you know you’re not protected.  Only you and your lawyer can protect you — no matter what lines the union sells when it’s time to agree to have your dues deducted from your check.

My advice:  Keep a lawyer on retainer and speed dial.  Nope, I can’t be your lawyer.  I have a full-time government job where I can’t take outside cases.  If I didn’t, stupid management and union decisions could easily buy me a bigger Beemer.

A book recommendation

I rarely recommend books, but I’m in the process of reading a book that I cannot recommend enough to each of you.  As many of y’all know, I’m a huge Dick Cheney fan.  Ok, I may be the ONLY Dick Cheney fan….(I’m still waiting on my pass to visit the Secure Undisclosed Location and my bonus in Halliburton stock.)   Recently, Vice President Cheney co-wrote a book along with his cardiologist, Dr. Jonathan Reiner.  That book is called Heart: An American Medical Odyssey.  This book is fascinating.  It’s an incredible mix of politics, the history and progression of cardiac care in the United States, and perhaps, most interestingly, the relationship between a physician and his patient.  Even more amazingly, for a mass market non-fiction book, Dr. Reiner’s parts of the book are heavily detailed in all aspects, from the underlying pathophysiology, the pharmacology, and the interventions performed.  The book, at least to me, is a rare treat – a combination of politics, autobiography, and more than enough medicine – and cardiology in particular – to satisfy someone like me who has their feet planted in both the legal/political arena and the medical arena.  Highly recommended.