Posted on

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.

~~~

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.

~~~

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.

Posted on

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.

Posted on

Discontent Breeds Distrust and Confirms Bias

I am not a very fast writer. My vacillation and rewriting means I miss the hot take. Case in point: An unidentified bearded man in jean shorts scrawled scandalous messages and awful claims on ambulances and buildings owned by FDNY. In my queue there currently sits draft number two of a post on public perception of EMS. More specifically, how social media griping fuels public distrust of EMS.

This rewritten piece originally began as my thoughts on lambasting EMS on social media. It was timely that this serial tagger struck. With several FDNY personnel able to keep jobs in the sunlight of past illegal behavior, it surprised me little that a person would label (literally) ambulances with horrible things. While I did not search out any

But this is what I was beginning to see. When lawsuits are made public, current and former employees (anonymous posters who identify themselves as such) concur with facts of the case. We cannot ignore all of these discontents as simply fed up. Some may have legitimate complaints; the majority just want to assign misplaced hatred or distrust of whatever on the large company. But when someone, posting with “authority of knowledge” by having worked for the agency being sued, claims this is standard operations for the company, it brings disrepute upon those who employed. We all know a few who struggle, but they do not represent the workforce as a whole.

It began affect me!
I am an insider. I sit around the picnic table and hear the gripes and suffer the same poorly thought out schemes. Yet I am not on social media broadcasting issues making them appear to be similar to every single ambulance service. My employer has had some press-worthy data breaches. Looky-loo nurses perused medical records of those they shouldn’t have and it made the news. As a result, I’ve sat in the ambulance deflecting suspicious inquiry of me, and my integrity when it comes to the electronic medical record (EMR) system.

But that is less hurtful than another EMS provider doing something stupid. No, let me say this: It is more hurtful to see a string of replies on social media that confirm all ambulance services are like this. That is not a quote; rather it is a generalization of any number of ways some anonymous malcontents inflict disrepute on his or her former employer.

I will not name the most derided multi-state provider of EMS care in the country. Suffice it to say, I’ve read some very negative things about the company. Enter “I hate [this company]” and you’ll likely find a sub Reddit. Anyone with a gripe against this company, EMS providers, poor service, “corporate America” or any popular diatribe will find their biases confirmed.

This summer I had the pleasure of traveling to two cities where this outfit provides EMS. I couldn’t help but wonder if the two crew members in there were proficient, happy, caring about those they encounter, overworked, so incompetent through the mismanagement of their overseers, etc. Some of those claims are legitimate; others are not and are painted with a broad brush. But I’ve had it so ingrained from reading social media posts I see their rig and fear for my life should I need an ambulance. I can reasonable decipher the list and extract those issues with legitimacy. The general public may not.

Who do they really hurt?
So who pays for such foul reputation? Not the company. Because of the Keyboard Warrior, an underpaid and overworked EMT or paramedic struggles to care for an untrusting patient who fears he or she may not make it to the hospital.

This is horrible to think. I say to those disgruntled internet posters, where do these multi-state companies get their employees? Do they fly in out-of-towners who couldn’t care less about who they treat or what they do to the community? Or do they employ local people? That is about as close as I will come to defending any ambulance service. My aim is not to prove a subset of employees wrong. I just want to remind them there are still people working there who care for people.

Ok. We know you hate your employer (or former employer). And you have grievances. But can you pause for a few seconds to reconsider a Tweet or Facebook post that harms current EMS professionals and the system people rely on?

Posted on

Empty suit?

I’ve always found Brian Behn’s posts at emsqaqi thought-provoking, forward thinking, and reasoned. His “The Empty Suits of EMS” was a bit different. It took a more negative edge than normal… something I felt with each paragraph. This time, his pithy, lighthearted needle poking at EMS was a rusty machete swung with the vigor of someone exacting revenge. Behn’s victim in this case were leaders of an industry that is changing struggling.

I did read his atonement at the end. Alas, by then it was too late. Behn’s vitriol exposed his disdain for those not working the streets anymore. Be they C-suite suits, educators (maybe working one shift a quarter for “street cred”), or CCEMT-Ps and flight medics showing off like Top Gun pilots at a Civil Air Patrol conference.

Empty Suit or Bad Leader?
Empty suits? I cannot defend. There are great leaders, poor leaders and leaders quickly forgotten because they were neither. There are too many individuals; and for every one admirable leader, each of us can recall one or more leaders we regret knowing. Yet poor leaders and those quickly forgotten do not push boundaries of EMS. Rather, they maintain the status quo and look out for their own career. They fear failure and micromanage subordinates as to prevent their reputation from being tarnished. On this Behn is correct. Yet not all leaders can be categorized by the worst amongst them. Exceptional leaders figure out how to make gains by working to better the profession through their agency. The best try to mitigate pain. Yet on occasion, pioneers create situations where pain cannot be completely avoided. With change bumps are inevitable, organizations grow from them.

There were many points to address in Behn’s blog article. Yet degree bearing paramedics is a crucial item that needs to be discussed ad nauseam. This does hit close to home. I work for an agency that now requires new paramedic hires to have (or complete with in six months) his or her Associates Degree (AD). It is difficult to know for sure if scant applications are due to this requirement or an industry-wide shortage.

Why a Degree?
Throughout my undergrad and graduate coursework (which was always focused on EMS), I argued the same point. Currently, demanding paramedics earn a degree is a barrier. Paramedics want to get out there as quickly as possible. There are extrinsic attractors to prehospital work that are not necessarily more powerful than two or four years of college work. And the reality is, many paramedics are not interested in writing ten page papers. Hell, including pertinent negatives is a chore for many. And it is true, more paramedics outside the United States have university degrees. From reading, however, foreign paramedics are not much happier. They spend four or more years getting a university degree to do roughly what we can do in America or work with physicians on their rigs.

With that said, like Behn, I promote the idea of paramedics getting a degree. For an upper level research class, I designed a prospective study to measure certain differences novice paramedics with an AD and those without. Assuming an AD would focus on general education college-level classes and not advanced A&P or pathophysiology, logic and cognitive ability would be the focus of study. Other fields have shown some improvement in performance when degrees are required. But, does that necessarily translate to prehospital practitioners? No one has studied this according to my literature searches.

Advanced, To What Degree?
This begs the question, which will come first: Degreed paramedics or advanced prehospital practitioners? Will a wider scope of practice simply be bestowed upon paramedics out of legislator benevolence? Will medical directors find it in their hearts to allow more autonomous treatment decisions for no reason? Or do we need to stock ambulance services with more educated clinicians before these events happen? I harp on this point because it needs to be addressed. Do we continue to avoid demanding degrees because college educations are inconvenient or those attracted to EMS are less didactic and more hands-on? Doing what we’ve been doing is an easy way out. One that leads to keeping us trusted as technicians rather than clinicians.

Perhaps we stop dwelling on what prevents paramedics from earning degrees and begin encourage degree bearing colleagues. Yes, pay is low. But wages are derived from reimbursement. [Put high call volume and staffing shortages aside.]. Higher reimbursement follows higher capabilities. CMS compensate physicians who use new technology at higher rates to help defray costs of new technology and compensate for the learning curve. If EMS never pushes barriers, stays in present mode, there is no incentive for third party payers.

I did suggest leaders make some bold moves, which may cause discomfort within their agency. Such moves, if failures, may sacrifice their careers. Why can’t we suggest new paramedics take a similar risk? I earned two degrees for intrinsics, the extrinsic have yet to pay-off. In six years to rack up almost debt amounting to 2/3s of my annual income. I get it, my career was solid and it was a personal choice. My degree was a goal of mine regardless of where it took me within EMS.

Cognizant of this, I respect that my situation does not fit all. And one’s situation is a poor template for a whole field. Going full steam into “entry requires a degree” would be detrimental. Studies have shown when supplementary education goes up but permissions and capability does not, paramedics leave the field. Those who desire more leave disillusioned and frustrated. If they stay in medicine; in fields where they’ll be able to apply what they’ve learned. One logical choices is RN.

There I said it. RN. The group paramedics love to elevate themselves above. Yet registered nursing is not an allied health profession. It is a full-blown licensed profession. Leaps-and-bounds beyond what protocol-bound adrenalin junkies are in reality. Consider this, by the year 2020, the Institute of Medicine (IOM) desires to see 80% of registered nurses hold a BSN. Where are we as a profession? Complaining of low pay, no freedom to treat patients and getting treated like crap from nurses and doctors. Therefore, comparing RNs to Paramedics is like apples to oranges.

We are What We Are.
What other allied health professions are out there? [What is an Allied Health profession? Read U.S. Code here.] There is a sizable list by the Association of Schools of Allied Health Professions (ASAHP). Most therapists (physical, occupational, speech) are allied health professionals. I learned that Master degrees for physical therapists are no longer offered in the United States, after certification the default degree is a Doctorate (DPT). We are eons away from this!

Hold the Phone, Now it Makes Sense
I planned to continue my unsolicited rebuttal. Then I stopped to read the linked article after which Behn modeled his. To be honest, I now can see what Behn tried to do. Unfortunately, it did not work. Perhaps it was too personal or Behn wrote it with one leader in mind. Regardless, I stand by my analogy of hacking away with a machete fueled by a personal vendetta. Behn linked to a post by Nassim Nicholas Taleb, critical thinker extraordinaire. In it, Taleb lampoons everyone who thinks themselves so intellectual to be better. Not only do “Intellectuals Yet Idiots” (IYI) only understand scientific “realities” on a superficial level. IYIs are prone to be hypocrites who jump on the next scientific fad, often doing a 180 degree turn from what they once held as sacrosanct.

Taleb did not pull any punches for groups on either side of an (scientific or political) issue. I believe Behn missed the equal opportunity skewering to make his post more palatable. To be in concert with Taleb, Behn should have addressed those in the street who suffer a Mightier than Thou mindset. Instead, Behn’s theme implied: If you are not in the street, you are not EMS. Again, I am not discounting his sentiments wholesale; rather, valid points are lost for me by Behn’s inelegance. Ok, so your EMS Chief may not have been the most adept at scene management. Conversely, could the average Tip-of-the-Spear medic gain votes on legislation to buy body armor or provide line of duty death benefits? Can one be both the tip of the spear, focusing on day-to-day minutia and the one wielding it at targets far and abroad? How about extending or winning contracts with municipalities? How long would day-to-day operations go on smoothly or otherwise without “disconnected” management? We all play a part in EMS. Often left off of EMS is “system.” Systems that provide 24/7/365 medical care are not comprised of 16 daily two person ambulances alone. Nor do we, as a profession, grow without leaders who take risks and suffer the occasional miscalculations or stretch of pain.