Well, it’s once again EMS Week. Or to everyone else in healthcare who’s not an EMT or a paramedic (and yes, there’s a BIG honking difference), it’s Ambulance Driver Week.

And for most hospitals, that means y’all will feed us (don’t forget we’re a 24 hour operation) presuming the staff doesn’t graze over our meals as well and/or give us swag festooned with your hospital logo all over it. Don’t get me wrong. I love food. I love cold drinks. I can always use an extra pen or pair of shears. And I love the EMS room at a lot of the hospitals I’ve been to. Sometimes, that snack is all that’s keeping me, your facility, and our patients from me getting hangry.

But there’s more I’d appreciate from the hospitals, nurses, and doctors. Every year, during EMS Week, we hear how we’re your “valued partners in healthcare.” Valued partners get real recognition and partnership every week of the year, every day of the week. And there’s at least some of us who would like more of a partnership than a week with a taco bar or a regularly stocked EMS room. (Like I said, I won’t turn away food.)

But a real partnership means more than that. A real partnership means including us in education. I’ve lost count of how many colleagues in EMS education tell me about hospitals turning down EMS education programs’ requests for their hospital to be a site for clinical rotations. Those sites that do remain know they have EMS educators at their mercy and such clinical agreements have become something that it takes a lawyer to review, read, and understand. (Fortunately, I know an attorney who can do this.) Further, these clinical site agreements now have more and more restrictions on them, specifically now requiring the EMS education program to send a paid preceptor to supervise the students. A real partnership with EMS means allowing EMS students to “do things.” Labor and delivery rotations shouldn’t be “observation only,” especially when nursing staff loudly asks the mother “You don’t want a male EMT/paramedic student in here, do you?” Clinical shifts should be more than “observation or basic life support only” for paramedic students. I am tired of hearing pediatric facilities complain about their perception of EMS providers being weak at pediatrics when they won’t allow EMS students into their facilities or severely limit their participation as they tell us, “All you need to know is to bring the kid here. WE are the pediatric experts.” (And don’t get me started about a certain Houston pediatric hospital mandating that EMS get vital signs on the hospital’s blood pressure monitor as opposed to accepting EMS obtained vital signs.) And for the doctors who say that paramedics shouldn’t intubate or do other low frequency, high acuity skills, when will you allow EMS students as well as current providers the opportunity to get into the operating room to intubate or to shadow you?

There absolutely are EMS providers who are as passionate about professional development, growth, and excellence as anyone on the other side of the hospital doors. There are also those of us who pencil whip continuing education and have to be dragged kicking and screaming to accept changes in medicine. There are similar providers inside the hospital as well. I can usually recognize these folks when they refer to oxygen saturation as “O Two Stats.” But for those of us who want to learn, make these opportunities available to EMS. At least some of us will attend.

If we’re truly partners in healthcare, treat us as such. Allow this partnership to benefit our collective patient population. And if the altruism doesn’t convince you, consider this. I did my EMT rotations all at one hospital. I did all of my paramedic rotations in the emergency department and intensive care department at the larger hospital in the same network. My family has used that hospital network virtually exclusively since I obtained my EMS certifications. I have recommended this network and their physicians to many other friends. If nothing else, this hospital network opening their doors to a student has paid off many times to the network and their associated physicians, bringing them patients (and revenue) they would have never seen otherwise.

I truly do love the hospitals, nurses, and physicians that I get to work with regularly. I don’t expect tokens of thanks. I won’t turn down a cold drink or a snack. But the education and collaboration would be a special treat on EMS Week and every other week.

We’re getting closer and closer to EMS Week. What does that mean? For many of us, it leads to a slice of cold, cheap pizza and some random piece of EMS Week swag. For others, it’s a chance for them to prove their bona fides as either an “EMS leader,” “emerging leader,” or “opinion leader.” Most of these people will either share some sort of clickbait, shopworn idea, or conventional wisdom in order to remain relevant or to get clicks.

Since I preach from the pulpit of the “EMS Church of the Painful Truth,” I’ve never been relevant in the usual gang of EMS people trying to solve the problems they helped create nor am I cool enough to be worthy of clicks. As such, here we go with my take on where EMS is these days, at least in my part of Texas.

The hot topic in Texas EMS as of late is the impending dissolution of the MedStar system in Fort Worth and Tarrant County to be replaced by an EMS division of the Fort Worth Fire Department. There are a lot of unknowns (both known and unknown unknowns) about how this will look. Will the medics be covered by state civil service laws? Will the new FWFD EMS cover the other communities under MedStar? But one thing is clear to anyone who’s not a MedStar executive or an EMS consultant. The public utility model of EMS is broken. Contracting EMS out to a private contractor to operate “high performance EMS” (AKA posting at street corners) no longer works. With the current EMS shortage that’s been exacerbated during and after COVID, there’s no longer a steady stream of EMTs and paramedics willing to work 12 hour shifts driving around a metro area. In fact, both MedStar and EMSA in Oklahoma have been unable to find contractors who meet the performance goals, meaning that MedStar and EMSA have both been operating the system directly. And like Fort Worth, EMSA’s collapse is at the point that the Oklahoma City Fire Department has moved past running paramedic engine companies to putting their own ambulances in service as “supplemental transport units.” Whether MedStar and/or EMSA have failed to effectively persuade the public and/or elected officials of their value or the fire service is better at politics (and they are), the fact is that the fire service gets public relations and political power in ways that EMS has yet to accomplish, regardless of whether you show up once a year on Capitol Hill in a uniform that confuses EMS with a hotel doorman or a third world field marshal.

That brings me to my new controversial position. And it’s one I would’ve had myself admitted to a mental health facility for less than six months ago. Namely, if you do not have a well-funded third service public sector EMS agency (whether funded by the city, county, or a special tax district), the best option may well be a separate EMS division of the local fire department. Such a system needs to have a career track for single role paramedics that extends past the two of options of working on the ambulance until retirement or “promoting” to the suppression division. Several departments in Texas (Georgetown and The Colony) have single role medic positions with an EMS promotion track. While many urban fire departments still have a struggle with accepting the EMS role, there are many examples of smaller departments, especially suburban departments, where EMS excellence and the fire service are not mutually exclusive. And with the right leadership and commitment, even an EMS cesspool of an urban fire department can make the decision to improve. The fact that the District of Columbia’s Fire Department is now administering whole blood prehospital says that the impossible is sometimes merely the improbable.

Which brings me to leadership. I’ve been a bit of an EMS nomad over the years, usually because patience is still a skill that I’m working on. In many of these organizations, I see similar challenges. More than one formerly volunteer organization in a rural area transitions to a combination or potentially even a fully paid department as the rural area transitions to a suburban area. Along the way, the growth means that those hired early in the organization’s development promote into officer and chief positions. This growth becomes even more of a challenge based on the preexisting talent pool within many of these departments where people who weren’t competitive for positions with larger departments have now been at said small department long enough to have the seniority to promote into roles they may not be capable of performing. The “Peter Principle” is a real thing and we have more than a few EMS “leaders” who’ve been promoted to a level of incompetence. Worse yet? Once these people ruin an EMS system, they pollute the rest of EMS by hitting the EMS conference circuit and/or becoming EMS consultants. In the rural EMS setting, you’ll see something similar, yet different, where a crowd of locals controls the department to the detriment of anyone from outside the clique and/or with new ideas. “This is the way we’ve always done it” and “We’re just a poorly funded EMS system” are their catchphrases.

And that brings up my final controversial idea. Civil service protections are absolutely needed in EMS. Just like unions serve a needed role as a check on management, so too does civil service provide a check on management and/or political games in the EMS workplace. Yet civil service oftern has one other challenge. Namely, internal promotions. This means that new ideas rarely get brought into an organization because civil service limits promotions to those already employed by the organization. In some organizations, the chief can appoint their executive staff, but not always. My policy prescription? Allow for external hires of officer ranks with them serving in a probationary status like any other civil service position until vested in the system. Not only will it attract qualified people to a department, such new voices destroy the echo chamber that exists within so many civil service organizations. On a similar, related note — paramedic should not be a promotion position nor should it require the completion of a department’s “special” paramedic course (looking at y’all Boston EMS, Seattle Medic One, and King County Medic One). The only time someone in EMS should be promoted to paramedic is when an EMT employed by that organization obtains their paramedic and is moved into a paramedic slot. Likewise, the only initial paramedic course that an EMS agency should offer is an internal paramedic class for those EMT employees wishing to advance professionally.

There. Several hot, potentially controversial takes on EMS that you wouldn’t likely hear from one of the usual conference speakers or consultants. Remember, y’all, I can bring these opinions and others (as well as high quality EMS medical-legal education without BS or dogma) to your organization in the form of a lecture, presentation, or an appropriately titled and compensated full-time postion. As Captain Clay Higgins has said, “I’m easy to find….”

Over the last week, I’ve had some interesting conversations with some smart people in EMS. Likewise, I’ve had some conversations with people who think they’re smart. During the course of these conversations, I noticed that a common trait of these people is that they believe their intellect alone qualifies them to be trusted to enact their vision. These same people also believe that they know better than you. Further, you should just accept what they say because they’re “experts.”

I’ll start by taking an example from EMS history that has received a lot of attention in the last few years. There’s been significant discussion about Freedom House and why it shut down. What Doctors Peter Safar and Nancy Caroline did in the infancy of EMS and advanced life support was nothing short of remarkable. It was even more remarkable to get these results with a pool of medics of unemployed men from a marginalized community. The current narrative from many of those who’ve read the book American Sirens is that the only reason Freedom House went away was racism. I’ll NEVER deny the factor of race in American society. But the book also takes time to explain that neither of the doctors got involved in educating the city council about Freedom House and then lobbying the council for support of Freedom House. There was a note of shock and surprise from the doctors that politicians (and presumably the public) wouldn’t listen to them about the value of Freedom House – because they’re doctors.

As we’ve seen in debates about healthcare and public health ever since, the mere appeal to authority does not persuade the public. Expertise IS important. Even more important is the ability to be able to talk to people to convince them. Shaming, belittling, condescension, arrogance, elitism, and smugness not only fail to persuade others, but often (if not always) cause others to dig into their position even harder.

Sadly, there’s a few EMS influencers out there trying to change EMS who haven’t gotten that message yet. Several of these people have good ideas. But their attitude and delivery is so off-putting to others that they don’t even get to sell the message. Yes, we need better EMS education (and there might be some advantages to an actual EMS degree), we need an EMS association that advances the profession, and we need to address maintaining currency and competency for current clinicians. But no matter how compelling or correct your idea is, it won’t go anywhere if your tone and delivery ticks people off before you even finish. Worse yet, you won’t even get the time of day from actual decision makers, whether that’s a chief, medical director, public official, or elected official. Good ideas go nowhere without support. Obtaining support requires more than an appeal to authority. Most people don’t like being talked down to, meaning you have to overcome that before you can even begin to convince them.

Years ago, I read a book from former Speaker of the House Tip O’Neill. He said, “People like to be asked for their vote.” Ask people to support your idea. Don’t tell them to support it. And definitely don’t tell them they’re not smart enough to understand why you’re right and they’re not. Even if you don’t think you’re doing it, your tone and delivery may be saying otherwise. A computer or phone screen doesn’t convey tone well — and it’s easy for the tone to be misread. (Cue the multiple stories of “so-and-so isn’t that bad in person.” Those are usually followed by someone else telling you their social media persona is EXACTLY who and what they are.)

Life, and EMS, isn’t a social media echo chamber, Med Twitter, or an amen corner in a chat group of your friends who are convinced they alone have all the answers. If it was, we’d see a lot of these supposed experts in EMS with the influence to match their ego – and the results to match.

Last week, several EMS friends and colleagues asked me to look at the recent Kentucky case on EMS liability. Obviously, as a lawyer, my first and foremost answer is always going to be “it depends.” I’d also remind you that even appellate cases are incredibly dependent on the facts of the underlying case and the law in the relevant jurisdiction. If you’d like an in depth analysis of the case or how your organization can learn from this case, get in touch with me. I answer legal questions for a living, ya know?

Having said those disclaimers, though, there are a few things that stand out to me and bear discussion.

First and foremost, it’s quickly glossed over that the medics in question didn’t check their monitor and possibly not even their equipment. There’s no record of the daily check on either in this case. And the monitor failed to defibrillate when it needed to. As my torts professor at Texas Tech University’s School of Law used to remind us, “If there are damages, you must pay.”

Second, the court does an in depth analysis of the medics using the Active 911 phone app to navigate (incorrectly, no less) to the call when the policy manual for the department requires the use of the map book. By operating outside of department guidelines, the medics lost their qualified immunity at least under Kentucky law, under this set of facts. More on that to follow. I’d note two things, though. First, especially in rural or rapidly growing communities, maps are remarkably inaccurate no matter the source. Second, while I don’t have the trial transcripts, a good lawyer might have developed testimony to state that the Active 911 phone app does indeed constitute the use of a department approved map. Active 911 isn’t something people can just randomly download. The department has to subscribe to the service and it’s typically integrated into the Computer Assisted Dispatch (CAD) system.

So this all leads up to a long standing belief I’ve had — and it covers both the mapping issue and the equipment check issue. Namely, if you make it easier to do the right thing, people (typically even including your worst EMS providers) will do the right thing.

Over the years, I’ve encountered many such policies and processes that make it difficult for field providers to do the right thing — to the point that people either don’t do the right thing or don’t do anything at all. I’ll illustrate with a few examples over my nearly twenty years as an EMS professional.

Case # 1 – rural EMS system is worried about compliance and creates lots of policies and processes. One of those processes is to go with a system called Operative IQ for truck and bag checks to be completed at the beginning of each shift. Operative IQ in and of itself isn’t a bad platform. Like any IT solution, it’s all in the implementation. But this truck and bag check takes nearly 45 minutes — and double that time if there’s a spare truck quartered at your station. In other words, guess how many medics did a proper check of 45 plus minutes versus clicking through most things except the ones they deemed important or that required an actual number to be entered?

Case # 2A – As I call this, this is the story of the bags. I was at one rural EMS service that had a large Thomas pack on every ambulance. This was probably the heaviest bag I’ve ever carried in my EMS career. (Heck, if you want to use this bag for a physical fitness exam for new or current employees, let me know. I can hook you up with their chief.) The bag had a full assortment of trauma supplies, a D cylinder of oxygen, various oxygen masks, a complete set of intubation supplies, assessment supplies, and a full panoply of IV supplies. In other words, the bag had everything except one thing. Namely, any medications at all. Where were the medications at this service? Well, they were in a cabinet in the ambulance. Loose. (Except for the small amount of controlled meds which were in a small metal lockbox.) Again, guess how many crews took in the bag? Virtually none. To the point that the bag rarely even got checked. (By the way, did I mention that there wasn’t even an inventory or stocking list so you’d know what you’re supposed to have?) All but the least informed and laziest EMS clinicians know that it’s usually best to bring the gear to the patient and try to stabilize before transporting. But when you have a bag that makes it impossible to do so, you end up with 2 alternatives, both of which are bad. Option 1, just take the stretcher and get the patient in the ambulance. (At this service, this was VERY common with the BLS crews, who’d often resort to the funeral home days of EMS with throwing the patient on a stretcher and driving fast.) Option 2 was to bring in the Thomas pack and go back and forth to the ambulance getting the medications you needed from the shelf. Insert your favorite Benny Hill or Keystone Cops clip there.

Case # 2B – This is how you do it right. I worked at an EMS system on the far outskirts of Houston. They had their challenges – namely, try being the third crew member at a station with only two bedrooms and virtually no options to eat away from the tiny kitchen in the station. But the one thing they perfected was their bag design. First, the cardiac monitor’s pouches also held aspirin, nitroglycerin, and a glucometer. There was a trauma bag with everything to manage a traumatic injury (aside from pain medications) from bandaging and splinting supplies, IV supplies, “Stop the Bleed” type devices, and some basic assessment supplies. There was also a pediatric bag with the pouches color coded with the Broselow tape colors. But my absolute favorite was what they called the “ALS bag” that went in on every call. The bag had IV supplies, airway supplies (including endotracheal tubes and iGel devices), and medications. Better yet, the bag had two plastic cases in them. One was a case with all of the medications and supplies needed to handle an allergic reaction up to and through anaphylaxis. The other case (of a different color) had all of the medications and supplies to handle a hypoglycemic emergency. Finally, the spare medications in the ambulance were in a bag that could easily be removed from the shelf to handle an extended resuscitation or to treat a patient who needed more medications. In short, there was no reason you couldn’t bring the right supplies right to your patient each and every time. Oddly enough, while this service had its challenges, not bringing gear to the patient’s side was rarely, if ever, an issue.

Case # 3 – There are volunteer EMS organizations that issue bags (stocked at the appropriate certification level) to their members for them to respond to calls. That’s a great idea especially in areas where an EMS response may take a few minutes. But if you issue out bags and supplies to people, they need to know what they’re supposed to have AND be able to get the bag restocked without significant heartache or hassle. Otherwise, you end up with members either responding without the items they need to care for a patient or they don’t respond at all because they don’t believe they have what they need to respond. Anecdotally, we can see those things happening either by runs made by members or when a member turns in a bag that’s chock full of expired supplies and medications. How do you fix this? Step one is to make it easier to access the supply room. Step two. Organize the supply room and make the supplies easy to find. Bonus points if you have eager leadership who has taken ownership of the supply issues. Extra bonus points if the supply room now has all of the items that were on back order for eons now easy to find. (The gentleman I’m speaking of is my current EMS hero for this.) Step three. Make the supply/stocking list easy to access. Said current EMS hero recently made the organization’s protocols easy to access via a phone app — and the app includes the supply list for the bags. Speaking purely hypothetically, I know of at least one attorney/paramedic who now has a bag stocked to specifications and with the current meds.

In summary, most people are in emergency services, public safety, or healthcare because they want to help others. And most of those people know that they need to do the right things in order to help others. Most of us also have a relatively low BS tolerance. What does that mean? Procedures and policies that don’t work get ignored or there’s malicious compliance. That undermines respect for the organization, the leadership, and the procedures and policies that DO work. Further, when the bad thing happens (and it will), the lawyers have a field day. Even if the actions (or inactions) of these providers didn’t cause the bad outcome, there’s enough doubt to give a jury (or an insurance company) reason to question what really happened. It’s also a huge hit to the department’s reputation and the profession’s reputation as a whole.

For the leaders (whether formal or informal) in organizations, take a good look at your policies, procedures, and processes. See if they reflect reality. See how much of a “BS factor” there is to each and every one. Revise or even remove the ones that don’t make sense. And when you finally get to something that’s workable, hold people to account. Even if there’s not a negative outcome. Especially if there’s not a negative outcome. As we know, “just culture” doesn’t look at the outcome, it looks beyond that. On that note, when you bring someone in to talk about a violation, ask how and why it happened. Don’t immediately assume malicious or malevolent intent. The explanation might actually solve an underlying problem that you were never aware of. If it’s a department fault, fix it. If it’s an individual fault, remediate them or use the appropriate discipline. A policy that’s unenforced or not applied is a policy that a plaintiff’s lawyer will have a field day with.

As for those of us who aren’t in a leadership role, we need to let leadership know when something doesn’t work. Better yet, have a proposed solution. Hopefully, you’re in an organization that will take action on your concerns – whether making changes or providing insight as to how/why the changes can’t happen — or the current system actually works.

If you’ve made it this far, thanks. If I can be of help to you or your organization, I do make house (or station) calls.

Earlier this week, I watched a great documentary movie about the volunteer fire (and EMS) service called Odd Hours, No Pay, Cool Hat. The movie does a great job illustrating the various cultures of volunteer emergency services throughout the country as well as people’s motivation to volunteer and why they remain. As a volunteer myself (almost 19 years now), I saw a lot of myself in the movie and recognized some of the people I’ve worked with, even if the names and locations weren’t the same ones in Texas that I know.

Then, I looked at one of the departments they highlighted. Said department (which is NOT in a poor or rural backwater) wants their members to do a weekly night shift and a 24 hour Saturday shift every 4th week. That kind of schedule isn’t a volunteer schedule. It’s a part-time employee schedule. While this department was along the mid-Atlantic Eastern Seaboard, I’ve seen several volunteer fire and EMS departments in Texas that operate along the same scheduling concept. And the department that I spoke to in Texas seemed genuinely offended that I wasn’t able to meet their 48 hours per month commitment via a twelve hour shift weekly as opposed to my suggestion that I could come for two 24 hour shifts on the weekend. Apparently, at least there, they had a surplus of Texas licensed paramedics willing to work for free.

What I routinely see is the self-fulfilling prophecy that “we can’t get volunteers.” The truth is that volunteers are out there. The truth also remains that not everyone has the time, temperament, or inclination to basically work a part time job — especially with the added burdens of attending monthly meetings, fundraisers, committee meetings, and various mandatory trainings only offered at certain times. Even more so if you’re driving a way because of limited (or no) opportunities to function as an EMS provider or firefighter nearby.

Even the “hiring” process at volunteer organizations can be haphazard. People often don’t know that an organization exists, let alone is looking for volunteers. And attending a few “business meetings” to be voted in as a member, whether it’s a pro forma vote or a popularity contest undermines the notion that a volunteer department is truly staffed by “unpaid professionals.” Attending some department’s monthly meetings also demolishes that notion as you witness the lack of accountability, personal politics, self dealing, sense of entitlement, and rampant spending on pet projects. Thankfully, these are not issues at either of my current departments (one combination department and one entirely volunteer organization), but the stories ring true nationwide when my volunteer (and former volunteer) fire and EMS friends discuss their experiences. And those are just the issues that arise at the business meetings — not even addressing training, equipment, operations, and the other day to day issues that will either cause people to remain long term members or rage quit when the final straw breaks the camel’s back.

Volunteer fire and EMS is often its own worst enemy as it lowers standards, engages in petty politics, and creates a self-fulfilling prophecy of not being able to find volunteers. Oftentimes, they can’t fund volunteers because people don’t know they’re looking. Or if people do express an interest in volunteering, they are turned away because the volunteer organization only has one way to use them, whether it’s the failing model of the fixed duty calendar (see also: You’re working as a part time employee at this point and you should be paid as such.) or the idea that one must be all things to the department to be of any use. (See also: Most volunteer fire departments that turn away EMS-driven individuals. Pro-tip: Giving an “EMS-only” EMT or paramedic the keys to a squad truck means those who want to fight fire can do exactly that.) And of course, once a motivated member makes it through the malarkey and is still motivated, they’re all too often met with the conundrum of command staff playing the martyr, yet who are unwilling to delegate anything. The idea that new members need to pay their dues seems in direct contradiction to the martyr mindset of many chiefs and officers who simultaneously bemoan that the younger generation doesn’t want to help while also retaining their positions and duties even longer than some United States Senators. (For example, take a look at the interlocking boards of most of the EMS organizations and “stakeholder” panels where board members and stakeholders haven’t been on an ambulance or fire apparatus since there was a BioPhone and MAST trousers.)

Until we stop chasing the perfect volunteer and take what’s available to us, we’re doomed to the volunteer fire and EMS model being a historical relic that will, at best, limp along only because of the unwillingness of local governments to adequately fund emergency services. While we still have a volunteer or combination model for emergency services (by the way, there are reserve police officers too, even in large agencies), we have to either adapt our organization to reality or adapt the prospective volunteers to the organization. The former will be easier, no matter what the old guy in the back of the meeting says.

Otherwise, the stagnation will continue with the duty roster becoming more and more empty and no one wanting to “put up with that BS” to “work for free.”

I was discussing some issues with some EMS friends online this afternoon and the topic of physician and nurse involvement in EMS practice, policy, and regulation came up — and how physicians and nurses seem overrepresented when EMS policy is being set. The challenge is that while most of these physicians and nurses know more medicine than we do – we know more about how to deliver medicine in a non-clinical setting.

The overwhelming majority of people in EMS aren’t invested in their profession. (See also the posts regularly occurring on EMS social media asking basic questions about topics such as how to recertify. But that’s another rant.) And since they aren’t invested, they don’t care or do anything. Those that are invested rarely understand how to fix or change things. Sharing trivia and/or virtue signaling from Med Twitter and talking down to others is counterproductive. (In other words, “you’re a bad medic if you didn’t recognize this obscure EKG change” rarely encourages people to do better – or be better.) So is solely focusing on the clinical side of EMS. You have to understand operations, law, policy, business, economics, human resources and all of the other “soft skills” that the pedantic EMS science types scoff at. Why does the fire department get what they want? PR and politics. And we don’t do that.

Yet another example from this same group of friends discussing EMS policy — a state is discussing prehospital administration of blood products. (Shameless plug — Texas has no state scope of practice or state protocols to limit such an initiative.) The state invited a wide variety of attendees. The room had only two paramedics attending but was full of nurse trauma coordinators. And when the inevitable policy rollout happens that doesn’t count for the realities of prehospital care, you can guarantee that every medic in that state will complain about how “EMS is controlled by nurses.”

I know some highly intelligent people in my EMS family. And many of y’all know OMI much better than me, the ALS hobbyist. But I also know who to call at the state EMS office and can get them to call me back. I also know how rulemaking works and how a county budget gets approved. For the long term success of EMS, I’d say that’s every bit as important as knowing that OMI is the new fancy term replacing STEMI.

You may not be interested in politics. But politics is interested in you. And when that happens, knowing pharmacology may not be as helpful as knowing how the city approves your department’s budget, how the state health department can change the scope of practice, or how the county awards the contract for a vendor to provide EMS services.

First of all, apologies for not blogging in a while. Between practicing law during the day and two EMS roles that keep me busy, I tend to forget that I have a blog and only will wander over here when one of two things happen. One – when I get the email reminding me that I’ll be getting a bill for keeping the domain registration. Two – when something really inspires me. And right now, y’all are going to get both. And probably from both barrels.

This morning, I saw another one of those Twitter screenshots that goes viral around the EMS/emergency medicine/medical social media pages.

And said post upset and infuriated me. Not because of the truth or untruth of it, Rather, it’s trite and lacks understanding. So, as someone with quite a bit of education both in and outside of EMS and some experience with education and EMS policy, allow me to share my take.

Bluntly, I’m beyond tired of people comparing American EMS to EMS in any other country, particularly the United Kingdom, Australia, or Canada. All of these countries are dramatically different from the United States. Heck, compare EMS between different US states and you’ll see dramatic differences (Los Angeles County, California versus Texas – the land of delegated EMS practice.) Each of these countries have different forms of a national healthcare system and very different educational systems. (For example, an Australian bachelor’s degree is a three year degree as opposed to the typical four years here in the States.)

Bluntly, if American EMS is so awful, why does a large Louisiana-based private EMS concern keep getting Australian medics coming here? Could it be because maybe the grass isn’t necessarily greener in the Southern Hemisphere? The reality is that there’s a glut of degreed Australian medics and the jobs aren’t there.

If American EMS is so awful, where’s the peer reviewed studies comparing outcomes between American EMS and some of the countries with degreed medics? Most of the Med Twitter types that I see sharing these posts always want to “trust the science” and see the data. As of yet, I’ve not seen such data produced.

Oddly enough, American medics (well, excluding a few states that I won’t name like California) have a scope of practice that typically exceeds medics in these other countries. Securing an airway with paralytics, administering whole blood, and ventilators are common in progressive American EMS systems. In these other countries, they’re often reserved for graduate-level degree holding medics — or doctors. (Please note that, especially in the UK, flight crews are typically a medic and physician as opposed to our usual American model of a medic and a nurse.)

My blunt, candid take? A lot of these posts come from people who automatically assume that anything done outside of the borders of the United States is automatically better. Equally likely, these folks don’t understand the differences in EMS models, healthcare funding, and education that exist between the United States and these other countries. I’d also submit to you that many of these people haven’t had a great deal of exposure to EMS outside their own little corner of America — and assume that EMS is the same everywhere. It’s not

Can American EMS improve? Absolutely. Paramedicine shouldn’t be a jobs program for the fire union. Nor should it be delivered by the low bidder. And EMS providers of all levels shouldn’t be sitting in an ambulance for twelve hours a day driving all over town without an actual station to return to. Our education should not end at dropping the patient off in the emergency department. And we can fix much of this by beginning to educate the public about who we are and what we do.

That public outreach and education absolutely should NOT include selling American EMS short — and making us sound like the ignorant provincials that the Med Twitter illuminati think we are.

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.

https://www.ems1.com/ems-advocacy/articles/the-ems-workforce-critical-condition-uQLsAE6niAsqzjvA/

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.

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.