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.

(Another) reason why EMS isn’t taken seriously

EMS providers love to claim that “EMS isn’t taken seriously” by you-name-the-other-healthcare-profession.  And we’re right.  We rarely are taken seriously.  I’ve complained before about some of the reasons why.  (See also: T-shirts with flaming skulls and sayings about “Racing the Reaper” and “Doing Everything That a Doctor Does at 80 miles per hour.)

But today, I stumbled on another reason why we shouldn’t be taken seriously.   EMS professionals of all levels fail to grasp the science behind what we do.  I’m not talking about an EMT being unfamiliar with the Krebs cycle or even a paramedic not being able to explain why Trendelenburg is bunk.

What I’m talking about is more fundamental.  It’s about a failure to understand the scientific method, which subsequently adds to the continued issues with medics lacking critical thinking skills or understanding research.  This morning, I saw at least two experienced paramedics on Facebook hawking pseudoscientific woo as diet/health supplements.   Either they’re con artists or they lack the basic scientific literacy to understand that there’s ZERO science or evidence behind the overwhelming majority of these products.  Let’s not even discuss the amount of EMS providers who are vaccine deniers.  I won’t even give them the courtesy of invalidating their beliefs.  To me, vaccine deniers are the medical version of Holocaust deniers.

And then, there’s the other extreme in EMS.  We have the pedants who claim to be advocates of science and “evidence based medicine.”   All too often, though, these “experts” will immediately advocate massive changes in medical practice based on one journal article.  Sometimes, these experts don’t even critically analyze the article.  Patient who receive morphine in acute coronary events have worse outcomes?  Their solution?  Ban morphine administration.  Critical takeaway — most patients who receive morphine in acute coronary events receive morphine only because the nitroglycerine failed to relieve their chest pain.  Did it ever occur that the patients with more acute pain might be having a more extensive event?  Nope.  To the nattering nabobs of negativity who self-appoint themselves as “EMS research experts,” one journal article is enough to limit the EMS skills arsenal or drug formulary.  Yet, these same experts usually want multiple studies to enhance EMS skills or drugs because “the science hasn’t been proven yet.”  Folks, it’s a rare case when one journal article should change your practice.

I’ve blogged before about the shameful state of EMS legal education.  It’s somewhat understandable as EMS isn’t run by attorneys.  (And that’s probably a good thing, excluding your favorite blogger not named Kelly Grayson….)  But EMS is medical practice.  And medical practice is supposed to based upon science.  For EMS providers of any level to not understand the scientific method and inject a healthy dose of skepticism to most claims is to fail as medical providers.  And that, my dear minions, is yet another reason why we’re ambulance drivers and not healthcare professionals.

Controversy for the day.

Here’s another crazy idea for EMS.  I’ve heard it from several people in the past and I think I could get behind it.  What do y’all think?

Let’s separate the emergency response side of EMS from the pure interfacility transport realm.  Emergency calls and emergent responses to healthcare facilities (e.g. nursing homes and physician’s offices calling for a patient to be taken to the emergency department of a hospital) would continue to receive ambulances staffed by emergency medical technicians and paramedics.   Non-emergent interfacility transfers would receive a response from a transfer system.  Transfer systems would be staffed by nurses’ aides and vocational nurses who have received extra training and an endorsement in patient movement, patient transport, and vehicle operations.  As for the true “critical care” patients, the ones on multiple medications and/or ventilatory support, the minimum standard should be a true critical care paramedic.  In other words, a paramedic with a true critical care background (and yes, I realize there are a ton of competing critical care certifications) and possibly backed up by nursing and/or respiratory care practitioners.

A while back, I blogged about owning what you excel at.   EMS excels at providing emergent/acute care interventions on an unscheduled basis.  In other words, 911 calls and emergency responses.  Let’s focus on that.

It’s my blog…. (Endorsement warning)

And I’ll endorse candidates if I want to.  I run hot and cold on NAEMT because I know it’s the only association we have that can even claim to represent “all” of EMS, but I also see it fail to live up to its potential regularly — especially in terms of legislative advocacy.

These issues didn’t arise overnight and they certainly won’t be fixed overnight either.  Honestly, I don’t know whether to try to fix things or throw up my hands.   Today, though, I’m hoping that NAEMT can continue to improve.

One way that NAEMT can improve is with strong leaders on the board of director.  It’s truly my privilege and honor to endorse a friend and colleague as he seeks a position as an At-Large Director on the NAEMT Board of Directors.  Troy Tuke is the Assistant Fire Chief for EMS with the Clark County (Nevada) Fire Department.  I’ve known Troy (oops, Chief Tuke) for over seven years now since riding with him (when he was an engineer/paramedic) on my first trip to EMS Expo in Las Vegas.   Chief Tuke is one of the progressive minds in fire-based EMS.  (Yes, they do exist!)  He’s also a registered nurse.  In the years that I’ve known him, I’ve always known his integrity to be beyond reproach and that he is a continual advocate for EMS’s advancement as a profession.

If he doesn’t have three strikes already between being endorsed by an attorney, being a RN, and being a fire chief (I’m kidding, y’all!), I would highly encourage any NAEMT member to vote for Troy Tuke as an at-large director.

Thanks — and the snarky posts will be back soon.

Some sage advice from Sergeant Hulka.

Recently, a lot of EMS people online have fallen for some of the joke postings on a public safety version of The Onion called Call the Cops. Many of those people have gotten offended.  Apparently, making fun of ourselves offends the humorless.  These are usually the same people who are called upon to give the ethics lecture to medic students and who administer any pediatrics skills exams.

To these humorless sorts, I offer the following advice.

Hello world!

I’m new to blogging, but not to my passions which include the active practice of both law and paramedicine, good BBQ, and the occasional foray into politics.   I look forward to developing some devoted minions, I mean, readers.   I tend to be highly opinionated, blunt, and irreverent, so if you’re easily offended, you might not like this blog.   And as always, my opinions are my own, and not of any of my employers (whether past or present) or any EMS agencies I’ve been affiliated with.

About me?  I’m a Texas attorney and paramedic approaching middle age.  I actively practice both of my licensed careers — working as one of the minions of state government (NOT in EMS regulation, y’all) and volunteering as a paramedic and EMS educator.

Since I am an attorney, I’ll leave you with a couple of disclaimers.  All rights reserved.  No attorney/client or paramedic/patient relationship is assumed.  Contents may settle during shipping.  Shipping and handling not included.  Press hard, three copies.