Recruitment and Retention: More of the Same

I was thinking about some of the recruitment issues that EMS is facing. Lots of large, well known departments are having challenges filling paramedic vacancies. Over the last decade, many of them have gone away from double medic staffing because of the shortage of paramedics.

Yet, we all know of EMS services, most of which are smaller and/or lesser well known, that are approaching full staffing. Funny thing is that many of these services aren’t even the best paid in their area or state.

I think we need to look at them and see what they’re doing. My guess is that it has a lot to do with culture and working environment. Those things tend to keep people around a lot more than a department appearing in the EMS media and/or having a “celebrity” EMS chief or medical director. The truth is, having supportive management, a station to return back to, and equipment that consistently works is going to make more of a difference in your EMS career than “working under Celebrity Medical Director” who’s regularly published and presents at all of the EMS conferences. And here’s where I’ll issue my semi regular reminder that the “Gathering of Eagles” (which some rightfully refer to as the Gathering of Egos) represents the medical directors of the fifty largest EMS systems in the country, NOT the fifty best EMS systems in the country.

And while we’re talking about that, more than a few of those EMS “celebrities” remind me of Paris Hilton – famous for being famous. An EMS organization that’s social media savvy or has an extensive PR program can have an outsized influence or reputation that may not match their actual reality, either operationally or clinically.

In that spirit, I share the following link from EMS1. The article should be titled “Water is Wet” as the statements are obvious and it’s basically the usual EMS commentary. People trying to solve the problems they created in the first place.

If there is one thing that EMS excels at, it is our uncanny ability to believe that the people who created much of the current EMS mess, whether it’s education, operations, or clinical standards, can and should be trusted to sit on the next “blue ribbon panel” or “stakeholder group” to solve the problems they created in the first place. It’s little wonder that we still see EMS employers offering sign-on bonuses for so-called “high performance” EMS jobs which mean little more than a punishing call volume while you bounce around a city from parking lot to parking lot.

So long as EMS promotes the same celebrities who caused the problems they’re trying to solve, EMS will remain where it’s at. The solution? Look for the jobs at the departments that aren’t continuously hiring. Ask around. People who’ve been around for a few minutes in EMS know which jobs those are. Hiring bonuses, pizza parties, and self-promotion will only help a dysfunctional organization limp along so long. And until political leaders understand EMS and actually support EMS — with funding — these “celebrities” combined with the usual cabal of professional EMS committee members and stakeholders will continue to hold EMS back. And that extends absolutely to the current staffing crises we’re dealing with.

If you’re an EMS chief/director or a medical director and you’re wondering if this post is about you, it is well worth asking why people are leaving (or not applying). And actually addressing the problem rather than just boosting pay or giving incentives. People know the salary coming into a job. What they never know is what they have to put up with for the salary. Way too many EMS organizations ask people to put up with way too much for way too little salary. And that truth applies to volunteers too.

For Love of the Job

I have a few friends I consider extended family. One of them in particular feels like a brother from another mother. We have a similar taste for good food and sarcasm mixed with snark. And like me, he doesn’t do EMS full-time. He’s not paid either. He’s a pretty wicked smart (I think that’s the New England term) MBA who is in the financial sector full time and volunteers as a “paramedic light” and firefighter. He’s also acquired a taste for Texas BBQ. (You’re welcome for that trip to Cooper’s.)

He and I are in a group chat with several other like minded individuals. And yes, we’re probably talking about you.

But here’s what caught my eye this morning.

My friend mentioned the trust that the public places in us. The other night, he gets called for a six week old child with respiratory distress. In his own words, he says “it’s 99% likely panicking parent and 1% potential for ‘oh sh-t.'” Fortunately, the kid turns out to be ok. And I’ll quote his words on the next part, which is the key part. “Here’s the trust part: the other twin was crying so mom says ‘I have to get her’ and just hands me the little one. Has NO idea who these three guys standing in her living room are, never met or seen us before, we’re in a mix of regular clothes and ‘uniform,’ etc. Hands me the kiddo and goes upstairs like it’s nothing.” Exactly, my friend. Exactly.

He did a thorough assessment of the kiddo, then calmed the kiddo — and Mom and Dad. And whatever he was thinking about being woken up for what turned out to be a low acuity call, he made the patient and family feel as if they were all that mattered. (On that note, I’d note that there are more than a few paid EMS providers out there whose attitude is much less “professional” than my fellow volunteer in a small New England state.)

Years ago, a San Marcos cop told me that regardless of how silly it seems, to the person who called 911, it’s the most important thing that’s happened to them that day. It’s a lesson I try to remember when I’m responding and it’s the lesson I try to impart to those who I train and work with.

For those of us in emergency services and emergency medicine, we’re offered a ringside seat to humanity. Those who call us trust us implicitly. Let’s keep earning that trust. Train like it counts. Care for people like they’re your family. And never stop learning.

Earlier this week on Facebook, I said “Do the work. Be nice. Look like a professional. Polish your duty boots.” My friend from New England shared his experience that reminded me exactly why those things count — for both us and the public we’re trusted to care for. I hope I never violate that trust and that you don’t either.

What Does A Paramedic Need To Know?

When I was still a relatively new paramedic, I took an EMS instructor class. My instructor had also taught my paramedic course. While I’ve forgotten a lot about drafting lesson plans (which I think may be the educational version of nursing care plans — taught in school and rarely used in practice), I do remember him emphasizing the difference between “need to know” and “nice to know” when teaching.

Yesterday, while talking to an EMS friend, they mentioned that their service does a promotional exam to promote to paramedic. (Yeah, don’t get me started on the idea that paramedic is a promotion. The idea of not using someone’s education and skills to their full potential from the get-go is short sighted, especially while there’s a paramedic shortage.) They then mentioned the extremely low pass rate on this exam. Another thing I remember from my EMS instructor coursework and many other educational settings is that a low pass rate on an exam usually reflects a problem with the education, not with the students.

Then we discussed some of the exam, which included some subtle EKG minutiae about hyperkalemia criteria. That led me to thinking about how EMS education and exams love to focus on EKG details, especially 12 leads. And once I got to thinking about that, I decided to discuss this with some of my network of EMS friends, all of whom are smarter than me. The unanimous conclusion from them was that knowing specific EKG details for hyperkalemia probably wasn’t the best test of a paramedic’s knowledge. In fact, two of them (one an experienced paramedic who’s now an ED charge nurse and the other is a paramedic who’s now an advanced practice nurse) said their expectation was that a paramedic should recognize the peaked T waves on an EKG and report their findings as hyperkalemia should be diagnosed and treated based upon lab values. (By the way, I should mention that many paramedics, including me, have a very limited understanding of lab values in large part because our education doesn’t include that.)

This then led to several of us discussing what a paramedic should know — and what an assessment of said knowledge should look like. This led to a snarky, yet accurate comment from the advanced practice nurse. They said they’d be impressed by a paramedic who does three things.

  1. Take a good history.
  2. Bring patients to the appropriate hospital.
  3. Think beyond the next hour or two of treatment.

These seem to be skills that a paramedic should master and have down but seem to be regularly lacking.

I began to wonder why this is the case and my conclusion is simple. EMS education is heavily focused on solely the “emergency” aspect of healthcare. Most of our clinical rotations are in the emergency department of a hospital or on an ambulance. Needless to say, that makes a ton of sense. The challenge is that such an educational model and mindset leads to clinicians who have tunnel vision and little, if any, understanding of the rest of medicine. And that feeds right back into those three things that would impress the advanced practice nurse (and me, for that matter.)

The question is how to fix EMS education to give students more understanding of medicine and healthcare outside of the “emergency” setting. Not only would this understanding of medicine as a whole benefit our “emergency” patients, it would benefit our less acute patients who call EMS because we are their safety net and/or in their mind is having an emergency. As anyone who’s been in EMS for more than a few minutes recognizes, our patients’ definition of emergency doesn’t always match with our education and skill set of what constitutes an emergency.

First and foremost, every EMS initial education class from EMT on up should have a lesson on how EMS fits into the healthcare system. That lesson should be expanded, especially at the paramedic level, to discuss the different specialties of medicine and the roles of other healthcare practitioners. The lesson should also include discussion of hospital capabilities. And part of the field training and orientation process for an EMS provider MUST include a thorough orientation to the local hospitals that their EMS system transports to.

One other thing. EMS clinical rotations, especially at the paramedic level, need to include exposure to other parts of medicine. In an ideal world, I’d include a rotation with a hospital based internal medicine physician to provide a better understanding of chronic and acute illnesses as well as to provide at least an exposure to the types of medical cases that are routinely admitted. (By the way, there’s study after study showing that EMS clinicians routinely lack the ability to determine which patients who present to EMS are “sick enough” to be admitted to the hospital.)

Until we get EMS to embrace the medicine part of EMS as much as we embrace the emergency part of EMS, we’re going to remain the “ambulance drivers” without a place at the healthcare table. And no amount of discussion about EMS degrees, EMS 2.0, Med Twitter, or obsessing over EKG criteria will fix that.

FirstNet Fails

Anyone who knows me well knows that, outside of my passion for volunteer EMS, I also enjoy good food and sharing my opinions about good (and bad) food with reviews.  And more than a few of you know that the job that actually pays my bills is practicing law for state government where I routinely deal with government contracts and technology.

So, now that you know all of that, you might see why I feel qualified to give a review of FirstNet, the Federal government’s wireless communications initiative for public safety and public services that’s a public-private partnership with AT&T. My experiences aren’t isolated, as I’ve seen in multiple reviews on Yelp and Google as well as stories and complaints on Reddit and AT&T’s own discussion forums.

Generally speaking, the concept of FirstNet makes sense.  The idea of a wireless communications system designed to provide nationwide coverage for first responders and public service entities is an idea worth doing.  And a partnership between the Federal government and a national telecom company is imminently logical. The Federal government has the money and resources to partner with a national telecom company to provide the infrastructure for such a network.
I’ll say this much.  FirstNet is competitively priced.  The prices for its service are significantly lower than any other option.  And unlike most other wireless providers, FirstNet doesn’t throttle speeds and allows for unlimited tethering/hotspot use.  For someone who needs to complete reports in the field like I do at times, using my cell phone to provide a wi-fi signal to my tablet is a huge deal.

But those points are virtually the only advantages to FirstNet.  For one thing, their website for billing and subscriber services is, at best, clunky. For the first responder paying for their own phone on the network, the website is illogical and hard to navigate.  My best guess is that the web access was designed to be used by those managing multiple phones for an organization.

Let’s talk about FirstNet customer service for a moment. In short, it’s non-existent. The majority of customer service and sales comes from AT&T retail outlets.  Most of these stores are remarkably unaware of FirstNet and not every employee is capable of handling a FirstNet transaction.  When I first signed up for FirstNet, I had to call several AT&T retail locations before I could find someone to help me sign up.  And even at the location that promised someone to help me, I ended up being a training exercise while a new employee tried to navigate the FirstNet signup process.  I’ll return more to customer service as I expand on my biggest concern about FirstNet.

Even before 9/11, public safety recognized that interoperable communications and communications equipment were a weakness. FirstNet was and remains one of the Federal government’s cornerstone efforts to provide seamless, interoperable communications for emergency services. So, imagine my surprise when I’ve found that phones that are supposed to be FirstNet compatible aren’t. For radio communications, P25 digital systems are largely brand agnostic.  Motorola, Harris, EF Johnson, and others make P25 radios – all to the same standards. Yet, whether by oversight or intentionally, Android phones don’t seem to work on FirstNet unless you buy a phone from AT&T. When I first switched to Android, I bought a Samsung S20+ from Samsung.  The phone was unlocked and had FirstNet’s necessary Band 14 access.  Yet, I started to have problems with my phone not working on FirstNet. I went to the nearest AT&T store and was told that my unlocked phone that I bought from the manufacturer was not FirstNet compatible.  The AT&T store personnel switched me to a regular AT&T SIM card, but kept me as a FirstNet account.  In short, I was told I’d lose some of the network priority and preemption capabilities of FirstNet, but wouldn’t notice a difference.  That was fine until I switched to a Google Pixel 6 Pro that I bought directly from Google as an unlocked phone. Bluntly, the reason that I rarely buy phones from AT&T relate to the relative unavailability of phones at AT&T retail outlets, phones that usually have less storage capacity, and the significantly better financing and pricing offers from the phone manufacturers.

When I received my Google Pixel 6 Pro, I had some problems with getting the old SIM card in.  I went to the nearest AT&T store to get an e-SIM card activated. I was then told that NEITHER of my phones were FirstNet compatible and that they couldn’t activate either phone on FirstNet.  In fact, I was told that only AT&T phones had FirstNet capability because non AT&T phones rarely had Band 14 access. The “workaround” was to sign me up for a regular AT&T account with a first responder discount.  Not only is the plan slightly more expensive, it no longer has unlimited tethering/hotspot capabilities nor does it have the network priority/preemption capabilities.

As I had bought unlocked phones, I was quite confused and concerned that neither of my IMEI numbers showed to be FirstNet compatible.  I decided to contact the FirstNet Authority, which is the Federal oversight and planning agency for the implementation and management of the FirstNet program.  I sent an email to the FirstNet Authority and began to speak with the regional representative for Texas, who definitely understood and appreciated my concerns. He assured me that I did NOT have to purchase equipment from AT&T and told me of several agencies that purchased their wireless devices from other sources and had no issues with FirstNet compatibility.  He proposed getting me in touch with AT&T’s regional FirstNet representative for the Austin area.  The AT&T regional representative had a lot of explanations at first, including that many unlocked phones aren’t meant for the US market and that AT&T couldn’t guarantee their compatibility because of missing Band 14 coverage. I then informed the AT&T representative that both my Samsung and Google phones had been purchased from the manufacturer. The AT&T representative first said that I needed to change out my new phone for the AT&T specific model number and to contact Google for that. When I reached out to Google, their technical staff told me that the phone was unlocked for all carriers and that it had an unlocked bootlogger.  I was also directed to the technical specs for the Pixel 6 Pro which showed that all models have FirstNet Band 14 capabilities.  I then recontacted the AT&T representative who said that merely having Band 14 capabilities did not mean that the phone was guaranteed to be FirstNet compatible and that my model had not been certified.  Since sending the AT&T representative the technical specs from Google, AT&T went silent for a while, then I heard from them claiming that the IMEI number is invalid.  They continue to tell me that I may need to return the phone to Google to buy a FirstNet ready phone.  And presumably, that means an AT&T purchase since an unlocked phone purchased directly from the manufacturer somehow won’t work on FirstMet.  Again, I’m pointing out that FirstNet appears to be creating a situation where AT&T is the de facto sole source of FirstNet compatible devices, at least for Android. 

Considering this, I have emailed senior leadership at the FirstNet Authority as well as the National Telecommunications and Information Administration at the Department of Commerce, which oversees the FirstNet Authority.  Again without a response.

Now, here comes my government contracts attorney side.  One of the things I’ve learned with public-private partnerships is that the private entity rightfully wants to recoup their investment. Sometimes, though, that means that the private vendor will take steps to ensure that only their product can be used.  I’ve seen that before with state contracts for services such as fingerprinting services for applicants for state licenses. What’s odd about the case with FirstNet is that AT&T seems to be implicitly requiring the use of AT&T phones (at least in the Android world) to use FirstNet. Yet, the FirstNet Authority believes that the FirstNet platform is supposed to be an open platform for compatible devices. I’m unsure exactly what has happened, but it’s clear that AT&T has been given the keys to FirstNet and the FirstNet Authority is failing to oversee the contract. Whether AT&T’s actions are intentional or accidental, the FirstNet Authority exists, in large part, to ensure that the private vendor is operating within the bounds of their agreement with the government, even more so as a recipient of public funds.

In short, FirstNet is definitely failing to live up to the expectations of being an interoperable wireless communications network for emergency services and public service.  The failings of the FirstNet Authority to oversee the actions of their contractor, AT&T, have created a situation where AT&T has been given the gift of a Federally approved monopoly to sell wireless devices to our nations first responders.

Without action from the FirstNet Authority, I believe that the next logical steps are an investigation by the Department of Commerce’s Office of the Inspector General, the Government Accounting Office, and/or Congressional inquiries.

As for my “Yelp review” of FirstNet, it’s a one star. The price is excellent, but clearly AT&T has given the first responder community this pricing at the trade-off of being bound to AT&T for devices, which are often more expensive and less capable than readily available unlocked devices sold by the manufacturer.  While I am not an antitrust lawyer, this tactic, both in terms of consumer sales and government contracting, bears investigation for potential antitrust or consumer protection claims.

EMS Week Thoughts

Over the last week, which happened to be EMS Week, I tried to do a Facebook post each day with my thoughts on EMS for EMS Week. Here’s that collection for y’all…

Sunday, May 16

Happy EMS Week to my EMS friends and extended family.To those of my friends who aren’t in EMS, now’s your chance to ask questions. And please, understand that EMS, EMT, and Paramedic are not interchangeable terms. EMS is Emergency Medical Services — the organizations made up of people who provide prehospital medical care. EMTs are emergency medical technicians. And paramedics represent the highest level of education and skillset in prehospital care.

Monday, May 17

I’m going to try, with no guarantees (see, there’s my lawyer side showing) to do an EMS related post every day of this EMS Week. And since a lot of people are posting about their early days in EMS, I’ll shamelessly follow that trend. In 1999, as a bored second year law student at Texas Tech, I signed up to do a ride along with Lubbock EMS because the Lubbock Police didn’t allow rides. Needless to say, after just over sixteen hours with Jackie Buck on 9744 running a cardiac arrest and a really weird car wreck, I was hooked. I pretty much became a regular around Lubbock EMS and I realize how annoying I was as someone without any training. During my return trips home and prior to getting my EMT, I also had quite a few Austin/Travis County EMS crews putting up with me. (Thanks Warren Hassinger for always answering those emails…)In 2004, I got my EMT certification and started doing things for real at CE-Bar Fire Department/Travis County ESD 10. In 2006, I decided EMT wasn’t enough and by 2007, I got my Texas licensed paramedic patch…It’s been a heck of a ride and I wouldn’t give up the experiences, education, and most importantly, the friendships, for anything. I truly have the best of both worlds practicing both law and prehospital medicine.

Tuesday, May 18

Another #EMSWeek post. I’ve been a bit of an EMS nomad over the years, having volunteered up and down the I-35 corridor of Texas as well as the Houston/Gulf Coast area and the Texas Hill Country. I have the fortunate luxury of being able to walk away from EMS because of my primary career. But if you want to know how/why I’ve been a bit of a nomad, it’s simple. I know what I’m getting paid as an EMS volunteer. Namely nothing. Zilch. Nada. Zero. What I don’t know is what I’ll have to put up with at an EMS agency. In other words, how much do I have to put up with before I decide to move on?Most in EMS don’t have that ability. But we continually lose the best and brightest to other fields, especially nursing. Maybe it’s time to look at the culture of EMS, including how we treat our fellow medics and how we develop and promote leaders. Because, let’s face it, there’s easier ways to make $15/hour than to be micromanaged while moving from parking lot to parking lot for 12+ hours at a time. If we want EMS to remain a viable career (or even become a viable career), we’ve got to treat each other better, especially our employees. Otherwise, we will never improve because we will be in a constant cycle of hiring and replacing people who’ve left the profession for something else. In some cases, people leave EMS for ANYTHING else.This EMS Week, we must do better.

Wednesday, May 19

fancy themselves influencers. More than a few of them have taken positions on social and political issues. That’s fine, although my politics usually trend differently. More than a few pride themselves on not being prejudiced. Good for them.But one form of prejudice and bigotry exists on a lot of EMS pages and groups — and seems to be tolerated, if not outright promoted. Namely, bias against one group of EMS providers — volunteers. It’s the one place where the IAFF and the “social media influencers” of EBM and third service EMS meet.These people talk about morons as volunteers, talk about how volunteers take jobs from EMS, and how there’s “not volunteers running the library, picking up the trash, or fixing the streets.” Having experienced some of the mismanagement and shenanigans in volunteer fire and EMS, including the mindset that a volunteer status is an excuse for lowered standards, I empathize.But when I remind them that I’m a volunteer, I get the answer of “you’re different.” It reminds me of the excuse “some of my friends are of XYZ group” when you call out other forms of bigotry.Is there incompetence in volunteer EMS? Absolutely. I think we all know examples — and have seen it promoted. (See also: New Jersey First Aid Council.)However, volunteer emergency services, whether EMS or fire, can — and do — work. In many of these communities served by volunteers, the only alternative would be to have a large commercial EMS operation from a nearby area pick up the community and respond from even farther away, potentially leaving the area with even more substandard coverage.Volunteer EMS has its pros and cons — just like any other model of EMS system. It can work. It does work in some areas. It’s also an abject failure in other areas, especially when the cliques and personalities override patient care and responsibilities to the community.Having said that, bias against volunteer EMS service seems to remain the last acceptable prejudice in EMS circles, particularly on social media.

Thursday, May 20

And as threatened, here’s today’s #EMSWeek post. Two words that EMS routinely fails to grasp are promotion and education. In two cases, these terms are inextricably linked.1) We absolutely stink at public education and promoting who we are and what we do. We’ve largely succeeded in educating the public to “call 911 for an emergency.” Yet, we’ve never told the public what’s an “emergency.” Anyone who’s spent time in a 911 ambulance knows that our definition of emergency and the public’s definition don’t match up. Also, we haven’t told the public much about us or what our capabilities are. See also: members of the public using the terms ambulance driver, EMS, EMT, and paramedic interchangably. See also: questions like “why is there a fire truck when I called for an ambulance” or “what do you mean there’s a bill.” To get the raving fans in the public that other public services like the fire department, parks, and libraries have, we have got to create a generation of educated, raving fans who will advocate for EMS.2) Also speaking of promotion and education, we don’t educate or even prepare the people we promote. “Fred is a good medic. Let’s make him a training officer” is soon followed by “Fred is a good training officer. Let’s make him a supervisor.” None of this is accompanied with any leadership education. And when you don’t develop leaders, at best, you develop managers. Managers look at metrics and take direction, then pass it down the chain. In other words, there are a lot of EMS managers and damned few leaders. Think about that when you’re working for an EMS provider whose business model requires you to drive around town and park in 7-11 parking lots for 12 hour stretches. The abject lack of leaders who advocate for EMS and for their team are exactly why EMS is how it is, where it is, and why the current paradigm stinks. And to add fuel to the fire, there’s more than a few of the current (and previous) generation of EMS grand poobahs who continue to dominate the EMS committees, work groups, etc. They’re hanging on to their fading relevance and routinely tell new faces to “wait their turn.” Once again, EMS has met its enemy — and it’s often us.

Friday, May 21

Another #EMSWeek thought to ponder. It’s good, heck it’s imperative, to be current on one’s medicine. And it’s right that EMS education focuses on the application of science to medicine.But that’s just one part of being informed, educated, and successful in EMS. One also needs to understand the world of EMS operations — because what makes EMS different from most of the rest of the world of healthcare is where and how we deliver medical care — namely outside of clinical settings.And perhaps most importantly, we need to understand the business, economics, law, policy, and politics of EMS. Because if we don’t own those spaces — someone else will. And invariably, those people don’t necessarily have EMS’s best interests at heart. (See also: virtually every state or Federal EMS committee where the EMS practitioners are outnumbered by the other “stakeholders.”)

Saturday, May 22

Final #EMSWeek post. I’ll leave you with two thoughts. First, it’s a privilege to do this work. Strangers trust us to enter their lives at their worst moments and trust us to know and do what’s right for them. Second, EMS can be fun. For me, it’s a huge change of pace from the practice of law and the constant meetings, emails, and issues that drag on for a long time. As long as you keep those two things in mind — and have a life away from EMS as well, it puts everything else about EMS into perspective. And if you’re not having fun with this, ask yourself if it’s you or if it’s where you’re at.

EMS – Starting From Scratch

Right now, there’s some controversy in Texas EMS circles over a pilot program to combine EMT and paramedic education into a single program where an entry level student wouldn’t need to be an EMT before entering paramedic education. I am cautiously optimistic for this concept, but I’m also sure it will need tweaking along the way. EMS is the only career field I’m aware of, at least in healthcare, where you have to obtain a lower level certification in order to advance. Registered nurses don’t have to become vocational/practical nurses first. And physicians don’t start out as physician assistants.

In this spirit, I started to wonder what other sacred cows I’d slay. With my squirrel brain, that quickly morphed into how I, your humble scribe, would completely redesign EMS from scratch.

First, get rid of the Emergency Medical Responder certification — or what Texas calls Emergency Care Attendant. EMT becomes the new certification for first responders, whether police officers, firefighters, or other personnel. On that note, aside from politics and inertia, why do we have the fire department doing first response prior to EMS arrival? Why not have law enforcement or even community based organizations doing EMS first response?

AEMT would become the minimum staffing level for a 911 ambulance. Of course, there can and should be a process for rural communities to make the case for EMT level staffing due to unavailability of AEMT and/or paramedic staffing.

Non-emergent transfers would be done by nursing aides and/or vocational/practical nurses with training in operating a van and patient movement. Non-emergent transfers should not be part of the EMS world. EMS resources should be dedicated to 911/emergency calls and critical care transfers only. On that related note, medical facilities, especially skilled nursing facilities, should be required to use the 911 EMS system for emergency calls. These facilities should also be financially sanctioned for using the 911 EMS system when a transfer company is not able to respond to a non-emergent transfer.

To supplement the 911 AEMT/Paramedic crews, advanced practice paramedics with enhanced education and skill sets in critical care and community paramedicine riding in SUVs to supplement and assist on 911 calls. These paramedic clinicians should function as true physician extenders to help patients navigate the healthcare system, engage in alternatives to transport, and considering alternate destinations besides the hospital emergency department. A paramedic clinician with telemedicine capabilities and point of care lab testing could present a huge opportunity for cost savings throughout the healthcare system.

In my ideal EMS world, there would be 3 ways to become a paramedic. Much as some nursing programs have a bridge course for vocational/practical nurses to become registered nurses, EMS needs a paramedic transition curriculum for those who are already AEMTs. Also like nursing has alternative entry BSN programs for those with a bachelor’s degree, we need a route for a paramedic certificate as an add-on for those who already have a bachelor’s degree. In this revised EMS world, most people would get a bachelor’s in EMS that covers the current knowledge base as well as the things we don’t cover, but need to advance in EMS — courses in management, policy, economics of healthcare, and adult education methods. The ideal EMS degree should be preparing graduates not only as paramedics, but as the future managers and leaders of our profession.

The current proposal of creating the associate’s degree as the entry level EMS degree accomplishes little beyond awarding college hours for what is currently, by and large, a technical degree in the career/technical education side of the community college world. EMS is a medical field with more in common with nursing, respiratory therapy, and dare I even say, medicine than it has in common with career/technical education like diesel mechanics or heating and air conditioning repair.

Everyone wants to fix EMS, especially those of us in EMS. All but the most naïve realize that any solution is going to require funding. Funding is a challenge whether the service is directly funded by the government or whether EMS is a private entity. There’s one untapped source of EMS money that most of us aren’t considering. As the more astute in EMS know, the Center for Medicare/Medicaid Services (CMS) only reimburses EMS for transports, not treatment. Until EMS speaks with a united voice and focuses our Federal legislative efforts on this change as opposed to quixotic, feel good legislative initiatives, we are doomed to poor pay, poor equipment, and a seat at the kids’ table of the Thanksgiving dinner that is the American healthcare system.

Am I wrong on this? Maybe. But unlike a lot of the others purporting to speak for EMS, I’m not unwilling to challenge the status quo. Johnny and Roy are but a memory to the newer generation in EMS and it’s time that we stop considering the original model of EMS responding to cardiac events and collisions as what constitutes an EMS system, much less a functional, successful EMS system.

The Right EMS Degree

Because I haven’t thrown out any EMS dynamite in a while, here we go…

I oppose the idea of a mandated associates degree for paramedics. Much of what it will do is to guarantee a monopoly to community college programs. These programs are often judged by completion, not success on the licensing exam. Additionally, these programs are often unavailable in rural communities. Many of the community college programs have shown an unwillingness to provide distance education and/or adjusted schedules for students unable to do a full-time day program.

My solution? Make paramedic a post-bachelor’s certificate. By doing so, you’ve already guaranteed that you will have students who’ve demonstrated an ability to think critically, complete a course of study, and to communicate. In other words, much of the affective domain has already been evaluated and validated. I’d also surmise such a paradigm shift will have lower attrition and have graduates, who by the very nature of their education, have the familiarity with standardized testing to succeed at the National Registry as opposed to viewing it as a mysterious hurdle that represents the pinnacle of professional accomplishment. Whereas, the reality is that the National Registry represents the minimal competence to safely function as an entry level provider.

We’ve all said it’s easy to teach the skills of a paramedic, but it’s much harder to teach someone to think critically and relate to patients. By requiring a college degree before becoming a paramedic, we’ve already found people who know how to think and (hopefully) relate to others.

And before you say that paramedicine doesn’t pay well for someone with a bachelor’s degree, I’d encourage you to look at the salaries for teaching and social work, both of which require a bachelor’s at a minimum. The truth is that EMS can and does pay a decent salary to the motivated individuals who seek employment with the more professional EMS systems as opposed to the employers who operate on a “patch and a pulse” mentality. Eventually, bachelors’ level paramedics will require two things that many EMS systems are unwilling or unable to provide — namely a decent salary and a less toxic work environment.

This won’t (and can’t) happen overnight. I’d argue that we need to look at making this the requirement in the next ten to fifteen years. And to remove one obstacle, let’s agree from the outset to grandfather in everyone who’s licensed as a paramedic before that.

Further, let’s do two more controversial things at the same time. First, we need to demand that paramedic is the ONLY advanced provider in the field. No more “cardiac techs,” “Intermediate-99s,” or the like. Next, like any other real healthcare field, we should not require completion of a lower certification to enter a paramedic program. Paramedicine is a separate profession from the technician level providers and it’s time we recognize this.

In short, paramedicine needs to be a professional education, not a technical education — even if said technical education leads to a terminal level associate of applied arts/sciences with limited mobility into a bachelor’s degree.

If we don’t dream big, EMS professionals are destined to remain viewed as ambulance drivers by those in healthcare, business, and government who act surprised when you tell them there’s a difference between an EMT and a paramedic.

The Lawyer Says Enough

Many of you who know me, whether in person or via social media, know that I complain about people expecting free legal advice. Between you, me, and the fencepost, I’ve actually done quite a bit over the years for the EMS world, whether it’s for personal friends, EMS organizations, EMS publications, or EMS conferences.

This morning, I received a Facebook message from a college EMS faculty member with a very specific legal question that was clearly about an ongoing issue for their institution. When I told them that I did not have an immediate answer and would require research, they began to pout and ask where they could find the answer.

Here’s some reality. First, legal questions don’t always have a simple yes/no answer. As such, they require legal research. Second, legal questions, even seemingly innocent ones, can raise ethical issues. Notably, these issues can be made even more treacherous when you (typically your organization) is already represented by counsel. As I’ve noted in previous blog entries, asking for legal advice has the potential to create an attorney-client relationship. When such a relationship is created, it also creates obligations and responsibilities on me as an attorney that go well above and beyond answering a simple question.

I find it ironic that there are a lot in the EMS world, especially online, who state that volunteer EMS prevents EMS from receiving the compensation it deserves. There may be some validity to this argument, but said argument loses much of its support when EMS folks expect free legal advice. As I stated to today’s offender privately, this is the equivalent of me asking a paramedic to provide me with free transport or treatment — or asking an EMS instructor to provide me with an ACLS class for free. In other words, knowing how to research and how to synthesize the law is how I make my living to pay for my EMS hobby. (Slight sarcasm and exaggeration goes without saying there.)

I’ve heard from several of these types how they’re only asking me as a fellow EMS provider. I call BS on this. Most of these folks know more than a few EMS providers, often who have significantly more EMS experience that I do — whether as an EMS field provider, educator, or manager. What said other “peers” don’t have is a professional degree and license to give legal advice. They’re looking for “a lawyer told me XYZ is the answer.” As I’ve said earlier, that answer carries certain ethical as well as legal ramifications for me — and those aren’t things I’m likely to undertake for free for a Facebook friend I hadn’t talked to in years.

Over the years, I’ve considered some of what I do in the EMS legal realm a form of paying back to the EMS community that has given so much to me. I’ve made a ton of friends over the years, gained a ton of confidence, and occasionally used the knowledge to help others. But the sense of entitlement from others has gone too far.

I’ve given freely of my time and expertise at my own sacrifice for too long. I’ve always been willing to support our EMS community and advance the profession. But freely answering legal questions is not something I can do.

And since this isn’t the first time I’ve mentioned this — and how it causes ethical issues for me as a legal professional — I’m less likely to be as nice as I have been in the past. To the last person who asked for advice, congrats. You’ve given me the courage and impetus to start saying “no” to much of the EMS world.

If you want legal advice, understand you’re asking an attorney for it. Said professional expertise comes at a price. And that price includes a retainer agreement and payment for said expertise.

Where EMS and education collide

This morning, I read an article with great interest about our local EMS system using a physician assistant who’s also a paramedic to provide enhanced EMS care — both for acute patients and to divert non-acute patients from the emergency room. The truth is that such a program has a ton of merit and would probably benefit a lot of EMS systems. While the funding may not be there, I personally believe that controlling the loss of funds from unreimbursed ambulance transports might be worth the money alone.

But this article illustrates a bigger problem with EMS. Namely, that a paramedic certification leads nowhere, except maybe a paramedic to RN bridge. The truth is that we know a lot of things about emergency medicine — and if you’re a decent provider, a lot of that knowledge carries over into other aspects of medicine. But there’s no recognized mechanism to transfer that knowledge to another discipline. And even if it did transfer over, most people in EMS don’t have the pre-requisites to get into other programs. Me included as my BA was a very studied attempt in avoiding hard science courses at UT because those courses were used to weed out pre-med students.

And the funny thing is that a MD friend of mine said she never uses those courses in her work. The truth is that the health care education field requires the wrong prerequisites. They attract people who do well in science and not necessarily those with the ability to communicate or even those who want to be caregivers. We see the results regularly, especially with physicians, when we see a clinician who can describe lab values to the molecular level but can’t communicate with a patient or their family, let alone show empathy.

We need to address two things as EMS. First, we need to find ways to bring our skillset, clinical knowledge, and life experience into healthcare above and beyond the usual two options of being on the ambulance or being a “tech” in an emergency department. Second, we need to encourage those in health care academia to recognize that alternate pathways to higher education in medical care can and should be recognized. I’d much rather attract clinicians with a proven interest in medical care as well as exposure to medicine than I would people who’ve checked off the right arbitrary coursework and who’ve never seen a sick person, much less talked to one or their family.

The challenge is for us to convince everyone else that an EMS certification brings something to the table when we want to move past working on the ambulance or the emergency department.

On Associations

As most of y’all know, I’m a native Texan.  I’m proud of being a Texan.  (Just ask me about BBQ and our better country music.) I’m equally proud of Texas EMS.  I believe that our regulatory structure and environment have created some excellent EMS systems and some of the best EMS providers in the United States.

As many of you know (or should know), we now have a new state EMS association in Texas, the Association of Texas EMS Professionals. There have been a few nattering nabobs of negativity questioning the need for a state EMS association and/or the motives of the founders.

As a member of the association, a paramedic, and an attorney, I feel a bit qualified to explain why a state EMS association is a must, as well as what it should and shouldn’t be doing.

A state association of any sort exists for one primary reason — to advocate at the state capitol for the profession.  Primarily, that means legislative advocacy as well as advocacy with the regulatory agencies.  As we know, many of the EMS rules and regulations receive little input from EMS. It is well past time that we as EMS professionals advocate for own profession and identity rather than allowing other “stakeholders” to define the world of EMS.  As most EMS laws and regulations exist at the state level, having a voice at the state capitol is critical for EMS.

Our national EMS association, the National Association of EMTs, exists especially to advocate for EMS in Washington, DC with the federal government.  My occasional gripes aside, they’ve made great strides in giving EMS a voice both on Capitol Hill and with the myriad of federal agencies who have a regulatory stake in EMS.

I’ve heard some moans and gripes from some EMS folks who want our state association to intervene in employer/employee disputes and advocate for wage increases.  Quite simply, that’s not how this works. State associations don’t exist for this reason.  Local associations and/or unions are the best place for advocacy with a specific employer.

A stool needs three legs to stand.  EMS needs those same three legs to stand — and thrive. For me, those are memberships in associations that advocate nationally, on the state level, and the local level.

It’s time for Texas EMS to take the next step.  Join me and the other Texas EMS providers who’ve invested $49 in our future by ensuring we have a voice at the Texas Capitol.