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Rural EMS and Those Who Sacrifice are Amazing!

In January I attended the Arrowhead EMS Conference and Expo, Minnesota’s largest EMS conference.  Long before this, its 40th year, prehospital folks could simply refer to it as “Arrowhead.”  Kind of like Prince.  It takes place in Duluth, MN and caters to those in the northeast corner and east central portions of the state.  There is typically a sizable contingent from the Metro (Minneapolis and St. Paul, nearly 200 hundred miles away).

This was my first year at Arrowhead.  What struck me were the number of EMRs and EMTs in attendance. But then again, I wasn’t where Big City paramedics abound.

Acting as membership representative for both the Minnesota Ambulance Association and National Association of EMTs, I spoke with many volunteer EMRs. What became clear was better funded EMS systems we take for granted in the Metro. One common thread between urban and rural factions is the apathy towards legislative impact.  But I digress.

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For those unaware, EMRs or Emergency Medical Responders, are the base level of the prehospital system of response.  These men and women have basic knowledge of life saving skills.  Essentially, they open airways, perform CPR, protect patients from further harm (risking their own lives to extricate victims), and assist us with more advanced training.  

What super rural EMRs go through really hit home.  Call this my exposure to a world outside large, urban paid EMS. 

What I learned came during a breakout session.  Most EMRs drive upwards of 45 minutes to a scene.  Add to that from home in their personal vehicle.  What 15 person volunteer fire department could afford a take-home duty vehicle?  They then provide care alone for various amounts of time. Many face having to perform CPR through coordination with family… or by themselves due to inability or reluctance of others on scene.  Being closer than a deputy, they risk entering scenes not advertised as potentially hostile.  The list went on.  And my appreciation grew.

For context, the first scenario we waded through involved a snowmobile rider who hit a tree.  One mile deep on groomed trails, the sole EMR first to arrive had to find a ride to the patient.  This event was in a state forest, outside range of 800 mHz radios, let alone cell phone service.  A question about satellite phones was countered with one asking who would fund it?  As this single EMR assessed patients, the victim’s friend was distraught and provided more problems than assistance.  Additionally, snowmobiles zipped by, unaware of the crash.  About 20 minutes elapsed before more EMRs reached the scene and 30 minutes beyond that for the closes paramedic ambulance.  

Egress was complicated due to distance.  Both out to the ambulance, which could not get as close as the first arriving EMR’s personal vehicle and then to the landing zone for the helicopter (approximately 11 miles farther).  

They enlisted citizen snowmobile riders to cart out the unresponsive patient on a long backboard.  More accustomed to redlining it, these volunteer snowmobile riders had to go slow enough to allow others to walk next to the ride.  Well-rehearsed plans to meet the helicopter at one of 7 camping/picnic sites was out of the question.  Such a plan was reserved for summertime.  Currently, the roads and sites were buried deep under snow.  

In the real event, the EMR running the breakout stated patient contact time was about four hours.  Logistics, problem-solving, life sustaining efforts are commonly shouldered by these volunteers who form an essential component of EMS.

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There was no ulterior motive behind this post.  I simply wanted to express my amazement at these unsung heroes we in major metropolitan regions rarely consider.  But how many of us go camping in a state park; drive through remote areas of any state on a family vacation; or even respond as an air ambulance crew to a location hours from a level two trauma center?  

This story is one of a million that happen annually across these United States, held together by a network of volunteer EMRs.  It isn’t even a personal story; yet it made such an impact, I feel as if I was there.  [We cannot discount the scenario-based learning for immersion!].  To EMRs who serve your communities and risking life and limb to do so.  Thank you.

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Emotions for the Betterment of EMS

I was introduced to the work of Prof. DeSteno through the EdX course, Empathy and Emotional Intelligence at Work.  An article written by DeSteno was assigned, which simply laid out three emotions useful in goal achievement.  These three are, Gratitude; Compassion; and Pride.  I instantly saw compassion and pride relating to EMS.  Gratitude seems generic and could fit any profession.

Compassion and Pride: The Low hanging fruit

So as not to gloss over compassion and pride, allow me to address those emotions first.  Compassion is why many of us got into EMS.  And hopefully, it is what drives us to continue toiling odd hours, in all types of weather.  There are degree to which compassion comes easy.  I’ll get more into this with my exploration of gratitude, because I am finding they go hand-in-hand.  I am not even sure, in a context of EMS, compassion and gratitude are mutually exclusive.

Pride is necessary for personal satisfaction.  DeSteno wrote:

When [pride] is authentic, it signals to others that you are a capable and reliable person, which is how it evolved in the first place—as a way to raise one’s status in a group. People with greater authentic pride tend to attain their goals and have higher self-control.

Pride is why many wear EMS shirts and festoon personal vehicles with emblems.  It shows we are a part of something important, ready to help and enjoy promoting our profession.

Gratitude: The less obvious

Gratitude instantly brings to mind a gleeful tip to a helpful waiter.  The act of being grateful and overjoyed is difficult to plug into the EMS mindset.  I am not seeing a lot of gratitude on Twitter to ambulance agencies for be able to earn a check.  On the contrary, there is ingratitude for being paid so little.

Similarly, there is no appreciativeness to patients who call for transport so frequently their address causes everyone’s eyeballs to roll.  Interestingly, Dictionary.com lists “obligation” as a synonym for gratitude.  Yes, we are obligated by law to respond and render aid.  But who got into EMS feeling obligated, let alone joyful, to care for someone who requests unnecessary transport?  If this was the case, abandonment would not be such an issue!

In the psychological sense, DeSteno found gratitude relates to “greater average patience and self-control.”  In the context of a paramedic’s dealing with a frequent caller who has no real need for ambulance transport, issues arise when patience is worn so thin, the encounter results in a disciplinary problem.  Self-control fails; words or actions result in less than dignified care.

Turning this seeming negative into a positive, consider specific reasons each patient calls 911.  Look beyond their act of calling emergency medical service.  You and your partner likely surmise why 911 was called.  Even if you cannot do something about it for future encounters, recognizing there is a root cause can soften your demeanor to the person with a perceived need.  Be grateful you were summoned.  Show compassion for their need, even if it isn’t medical.  Take pride in your role as a community outreach provider; be thankful this person did not need lifesaving efforts.

And by all means, pass along this new found view on their situation.  Even if your ambulance service does not have a Community Paramedic program, perhaps hospital staff can work to resolve some issues the patient is experiencing.  This act of being gracious with your compassion and improve their existence, so you may help others.

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More on Degrees

Some may read the title as “moron degrees.” That is what it seems many in the debate regarding paramedics earning degrees believe them to be. An unnecessary and burdensome requirement only a moron would require. Ok, maybe that’s too harsh. I should not characterize all those who are against degrees for paramedics consider my side morons. Additionally, most temper his or her disagreement for a requirement with acquiescent encouragement to seek more education on their own.

Lack of research again

Consider for a moment the argument paramedics are not nurses. Most, if not all, research in cognitive enhancement with higher education involves nurses. There is a subtle irony in this debate. The fact that there is no evidence to ponder (degrees improve paramedics) is perhaps more of a convenience for paramedics who’ve never been trained to evaluate evidence! The point of this post is not a rehash the lack of evidence, but the disconnect paramedics have from research and education in a field driven by research and one in which education is paramount.

Lack of degree

Yes, no one magically becomes a genius who effortlessly parses evidence-based best practices because they earned a degree (unless they become an epidemiologist or statistician!). However, medicine is now a certification-dependent domain. Even a person with a uniquely intrinsic understanding of medicine cannot “challenge” the USMLE to become a doctor. As I’ve pondered in other posts: Are paramedics so different that research in other fields (e.g. nursing) cannot be applied to paramedics?

Good reasons exist why motivated and intuitive people cannot become nurses, physical therapists or physicians by taking a test without training. There are minimum standards built around precise education which need to be met. Paramedic training is no different. To be eligible for state or national certification, candidates must attend an accredited program. Accredited programs follow a proscribe curriculum. Yet paramedicine explores little outside of a narrow scope of conditions and pharmaceutical arsenal. Even less so is the academic rigor necessary to understand medical literature. Students may read periodicals, like JEMS and EMSWorld. For what it’s worth, they are not medical journals; they are trade journals. These publications provide industry news and refresher-type material on medical conditions. However, they do not inherently advance medical practice. Consider them just-in-time training.

Articles in these magazines are important and speak to their intended audience. To digress for a moment, is the average paramedic able to evaluate a research article in Prehospital Emergency Care or Annals of Emergency Medicine? I am not talking about the ability to scrutinize the statistical power or run a chi-square distribution to assess research validity. I am speaking of a capability to assess if the hypothesis was answered by the results. Can one agree with the researchers beyond “gut feeling” or anecdotal experiences? This matters for alteration of practice. Want to rid EMS of c-collars? Start with literature.

Despite my slight digression, I find the inability for paramedicine to establish its own scientific foundation – what some might call evidence-based practice – a major contributor to paramedics remaining an afterthought in the healthcare continuum. Or, perhaps this is another chicken-and-egg conundrum? I will grant this consideration. Yet as important as appreciation for root causes and “how it used to be,” there is no point in lamenting the past, especially when it stunts our future.

Professional advancement

Which integrated member of medical teams do not need degrees? Nursing Assistants, Medical Assistants and Dental Assistants. In medicolegal terms, they have no independence. These assistants carryout orders and do essential but menial tasks. They preform simple tasks to maximize doctors’ and nurses’ time for cognitive work and advanced skills only permitted to them. Paramedics (and to lesser extent EMTs) are extensions of physicians. We do so with varying degrees of freedom and act with implied trust of medical directors. But for how long? Operating at our educational status quo, rapidly advancing medical understanding will outpace our technician standing. Knowledge and thinking required to use developing equipment will require higher level medical professionals to work prehospital.

Conversely, think your occupation is so special? Creighton University offers paramedic certification in a two week course. Applicants must be a licensed physician or nurse with two years experience. This is offered to frame the debate.

Eat my dust

As a profession, we are way behind the curve not the steering wheel. The ambulance has left the station, driven by nurses who have more training, as we still look for the keys. I am referencing the recent program initiated by the Beverly Hills (CA) Fire Department. Skipping over Community Paramedics (about 200 extra hours of training, but no degree), nurses with advanced licenses are coming to the prehospital arena. Paramedics have no standing in the medical community, as trained providers to offer the level of care offered by Nurse Practitioners. Paramedics could have been working toward this over the last few decades. Unfortunately, we argue over what constitutes an attempt at intubation, laugh at MAST pants, and ridicule c-collars.

As professionals, we gripe about being treated poorly as simple drivers. But we don’t carry clout necessary in medicine – a degree. When it comes to healthcare professionals, advanced degrees and board certifications or fellowships are the prevailing currency. We cannot even agree on the benefits of a basic two year entry-level college degree. This is an age when “good sense” and “initiative” are not enough to work in medicine; even assistants need to get specific training and pass an occupational assessment. They do not need a degree… and neither do we.

Conclusion

The path to more responsibility, better acceptance, and increased professional self-determination is through education. Our profession won’t excel relying on a lack of evidence as evidence that paramedics are different, therefore we don’t need a degree. We aren’t going to win over medical doctors without evidence. And we aren’t going to change regulations without support of medical doctors.

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Paramedic degree and recruitment

One of the most often utilized arguments in the debate over paramedics and associate degrees is it will be a barrier to entry. What if this is the wrong tact? Could lack of recognition over a degree, in fact be what is preventing potential paramedics from becoming actual paramedics?

Just as there is no evidence-based data that degrees making a better paramedic, I couldn’t fathom survey data that exists measuring how many do not pursue paramedic because of concomitant degree.

This is something that’s been smoldering in the back of my mind for a few months. All I had was anecdotal accounts picked up from reading myriad sources over years. And observations of cultures that put a premium on a college education. I have to look no further than my wife’s parents. My father-in-law constantly informs my kids they can become a doctor, engineer or teacher; according to him, they have no choice. He is foreign-born and I can’t help but wonder how many cultures eschew paramedicine because there is no degreed prestige behind it?

Two items appeared in my Twitter timeline. I could no longer remain silent.

First, a “look inside” becoming a paramedic had a pull quote that spoke volumes [H/T NYC EMS Watch]. According to WJRT, Flint (MI) Assistant Fire Chief Edwards said EMS is “a great stepping stone for people looking to pursue other careers in the medical field.” Hey, on your way to a degreed medical position, why not stop in as a paramedic to get some real life experience! Flexible hours helps you go to school to be something else.

The second tweet was from Dale Loberger [HP_EMS], who expressed a desire to find common ground in this debate after reading EMS is Not Nursing! by Chief Becker. The crux of Chief Becker’s post lies on EMS’s high reliance on volunteers and different method of reimbursement. Both valid points. However, they are used as barriers to end debate on the topic.

After reading his post, I must ask: Are paramedics so good degrees are not needed; or so low on the cognitive hierarchy that degrees are unattainable? This is a somewhat facetious question. While I honestly do not think he questions intelligence, stating that EMS is different from nursing sets us apart. But without elaboration, there is room for doubt. I surmised from reading from several fire-based EMS writers, resistance to degree requirement is funding based. I get fire departments come from a tax-dependent, fixed-budget world. Half of my household’s income depends on local voters approving a tax levy or bonding bill every other year. In spite of this, school teachers must possess an undergraduate degree to work. And in Minnesota they fight for stringent educational requirements!

One line in Chief Becker’s article needs more exploration. He asked, “Since when is having a college degree evidence of being a professional?” Is he referring to a collective profession or individuals being professional? In my opinion, a college degree shows that an individual professional joined ranks of a profession by gaining more knowledge. Degrees are usually required for licensure, board certification or privileges. Unless one went to a so-called diploma mill, he or she has done significant work to earn a degree.

Do we want EMS to be a trade or profession?

If we work toward the latter, we may attract a more diverse workforce made up of those who represent cultures where degrees are an expectation.