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.

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.

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.

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.

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.

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.

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.