Implicit racial bias in EMS?

simongretton

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In the wake of the death of George Floyd, and hearing so much about racial disparities in society, I think it behooves all people of good will to look to our own lives and ask ourselves to what extent we are part of the problem, and to what extent we are part of the solution. With that in mind, this piece in EMS world highlights some uncomfortable truths for those of us working in emergency medical services. Most of us would be appalled to think we treated patients differently based on race, but sadly, it's not hard to find reports of implicit bias at work in EMS. I know this is uncomfortable stuff to have civil conversations about, but I think we owe it to the world, our profession, the communities we serve, and ourselves to look at this.
 

jdemt

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I don’t know how to respond to this. I think I can speak for many EMS professionals when I say that we’re tired. In the midst of a global pandemic we are already being put to the test. And now to top it all off we are having to add additional shifts and do additional work so the triggered citizens in our area can have a public temper tantrum. I am only speaking for myself but I come to this forum to forget about the world and learn about emergency medicine-not to be further inundated with politics and guilt. There are many problems in the world but I can say with complete confidence that every patient is treated the same on my ambulance. Society is making public service more and more difficult every day. I shouldn’t have to question every move I make based upon the color of my patients skin, but the more I see posts like this I find myself questioning my every move and thinking “is this a politically correct IV placement?” And in my personal opinion this is absolutely ridiculous. Of course the United Socialist State of Oregon thinks that EMS is racist. There are so many variables with analgesic administration that it would be almost impossible to do a quality study that correlates with skin tone. You would have to include local protocol, complete vital signs, nature of illness, and transport circumstances to name just a few. These are the things that I think about when it comes to analgesics not skin color. Long story short can there be any escape from the constant tiptoeing? I’m so tired. I already have patients questioning when I sniffle (allergies not COVID). I don’t know if I can take attacks of, “you don’t care about my pain because you’re white.”

Personal opinion only. Not trying to trigger anyone.
 
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simongretton

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I appreciate the sentiment. Far be it from me to judge anyone else, or to accuse anyone of providing different care based on race. I hear enough about this, that I feel the need to ask myself these questions, but I shouldn't be pointing fingers at anyone other than myself. Thanks again for responding.
 

VFlutter

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"unconscious racial bias" seems to be the scapegoat that can always be assumed but never disproven. Not implying it is not a real phenomenon than may in some cases translate to treatment decisions however there never seems to be reasonable burden of proof other than it fits a narrative and is an easy explanation as opposed to the multitude of factors that probably are responsible.
 

E tank

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This isn't the forum for this. And what will result in this kind of baiting is a lot of uncomfortable questions surrounding socio-cultural problems that are not very flattering. The simplistic "institutional racism" script is on shaky ground when more honestly scrutinized.

This isn't even published peer reviewed research and it's being reported by Oregon Public Broadcasting. Might as well be an opinion piece from Fox News on Hillary Clinton.
 
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mgr22

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jdemt, I may be risking the "triggered" label merely by responding to you, but here goes:

I think I understand the frustration you feel about dealing with politics. I feel that, too. I also accept that politics can't always be separated from substantive discussions about society. That's what we're having here.

We don't necessarily know what feels like racism to others. Perhaps there are changes we can make to increase the peace without compromising our own rights.

Sometimes we act in ways that are interpreted as bias. Sometimes those biases are real, even if we don't realize they're there. For example, when you said, "Of course, the United Socialist State of Oregon thinks that EMS is racist," I assumed you're biased against Oregon and are prone to generalizing. I could be wrong about both those points, but that's my impression.

I wouldn't want anyone to think I'm racist (or biased against Oregon :)). If there's something I say or do that makes people feel that way about me, I'd like to know. Maybe I can learn something important about the way I come across. That doesn't have to make me so preoccupied with my behavior, I have trouble functioning.

Regarding the Oregon study, I don't know how valid it is, but I agree with the OP that it doesn't hurt to reflect on the ways we practice and to consider the possibility that we can do better.
 
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simongretton

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Hey All. I was the one who originally posted this. Thanks for all the comments. I certainly don't want to be causing unnecessary controversy. I chose to post the thought/question here because it is something I have been thinking about, that I wanted to run by others in the field. If this isn't the forum for this I can certainly close the thread.
 

jdemt

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mgr22:

While I’m not triggered, I am confused. When did an EMS forum become a posting ground for “substantive” sociological discussion/debate? Instead of debating actual treatment modalities and clinical advances were here having a back and forth on whether or not EMS professionals have racial bias in their treatments (which to me is ridiculous). I’m willing to guess that none of this would be the case back in 2008-2012 because we were so “progressive” back then (the political motivation I’m speaking of). I would think that if this is a big enough problem to actually perform an anecdotal “scientific study” and spark a debate in 2020 of all years, that it would have been a problem back then too.

I think this saying applies to the actions and attitudes of a scary amount of people right now and it goes, “If it isn’t broken, fix it until it is”.

So riddle me this. What problem are we going to create in 2021?
 

E tank

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mgr22:
While I’m not triggered, I am confused. When did an EMS forum become a posting ground for “substantive” sociological discussion/debate?
Just to be clear...when I said this isn't the forum for this, I meant that it should be in the EMS lounge section....Not that we shouldn't be talking about it.
 
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simongretton

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Just to be clear...when I said this isn't the forum for this, I meant that it should be in the EMS lounge section....Not that we shouldn't be talking about it.
Thanks for that. I am new to this and have not done much on these forums in the past, so forgive me for posting in the wrong place. I can certainly take this elsewhere if that is more appropriate. Thanks again.
 

jdemt

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Here I go regretting the expression of my opinions again...lol

Simon: you don’t need to apologize. Far be it from me to limit discussions in any way.

I’m done arguing haha
 

mgr22

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Thanks for that. I am new to this and have not done much on these forums in the past, so forgive me for posting in the wrong place. I can certainly take this elsewhere if that is more appropriate. Thanks again.
Simongretton, we're just having a conversation. It's not a problem.
 

ffemt8978

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Belive me.. If it was a problem I'd have already been involved. I decided to go ahead and move it to the lounge.
 

DrParasite

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So I read the EMSword article on the study.... It looks like it took an issue (treating of pain management with narcotics), and took a very superficial analysis on why it wasn't given (because of the patient's race). Based on the study, black people received pain meds less often than white people. The study doesn't ask why morphine wasn't given (maybe it wasn't indicated, maybe other treatments were a higher priority, etc), only assuming that the reason was implied racism. as @VFlutter said, it fits a narrative, and is an easy explanation as opposed to the multitude of factors that probably are responsible.

How do you prove you don't suffer from unconscious racism? Many of our colleagues in law enforcement are going through that right now... and many of the claims that are being made about them are being supported by facts, however those facts are being portrayed with a district lack of context. Once you add that context, and you analyze why they are happening, you see that many of the facts actually made sense, and are not the result of racism, but of a particular set of circumstances. depending on your political leanings, you might agree or disagree with that statements.

Do we all have biases? absolutely. Do I think the 20 year old college student in the dorms who reaks of alcohol and is throwing up is just drunk? yep. am I going to treat the 20 year old black college student the same as the 20 year old white college student? give them a bucket, and say "in the bucket, not on me." That doesn't mean I'm being racist because I didn't start an 18G in the student's arm, administer 1 L of fluid, administrator zofran, do a 12 lead, and give narcs because the students abdomen is hurting after all that throwing up. If you think i should have, than I'm just a poor clinical provider, not someone who is allowing unconscious bias to affect my treatment plan.

If someone complains of pain, we do NEED to give them IV narcotic pain meds? if we don't, is that due to unconscious bias, or our clinical assessment that says it would be inappropriate? More importantly, should we be giving everyone narcs to prevent the (potentially false and incorrect) assumption of unconscious bias? Here is another one: if the black patient is in pain, and demands to be given pain meds, and you refuse, are you discriminating because of their race?

We can even tie this back to George Floyd: if he had been a white guy, same situation, would the EMS crew have worked the arrest right there, potentially giving him a higher chance of survival? was it institutional racism that made them chose to load and go and leave the scene, condemning him to die? or did they recognize an unsafe scene, with an angry crowd, and decide it was better for the EMS crew's safety to load and go, and assess in a safer location, and then start their interventions?
 

RenegadeRiker

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So, a few thoughts:

Distance, local protocols, etc. drive what we do to a large extent. A lot of black patients live in concentrated areas with relatively short transport times, and are serviced by agencies that maintain fairly conservative cultural and clinical practices for pain management, combined with high volumes. This is amplified when you factor in organizational and regulatory factors.

With that being said, there are certainly racists and racial biases in EMS. I’ve seen Klan affiliation stickers, outright expressions of racism, and yes, a considerable amount of subconscious and open bias. And I do think that these biases have driven patient care decisions. But proving it, or even determining ‘why’ it happened, is next to impossible with any available data set.

I do also think that there is an interesting other question here- namely, the racial composition of EMS. Most of us are white folks, and although I’m not saying that’s a bad thing, I think it is certainly relevant to our practice in that many of our people are introduced to issues not through a relevant cultural lens, but by another culture’s perception of an issue based on extremely slim understandings of clinical concepts. Sickle-cell is the ultimate example of this: it’s a disease process that primarily affects the black community and is primarily understood in EMS from one-page protocol sheets and lectures in paramedic school. The socio-economic implications, challenges of access to care and deeper health consequences are often glossed over, and for a service with short transport times or conservative protocols or both, it’s pretty easy to fall into the VOMIT + fluid bolus solution and perpetuate that model of care. And it’s not ‘wrong’ entirely. If they start giving fentanyl (especially in clinically-relevant doses) to every sickle-cell patient, they’ll often find themselves being questioned for deviation from the mean, accused of diversion and facing increased scrutiny in their decision-making. I think a lot of providers look at patients with chronic pain, or acute pain from events like sickle cell, and are judging not necessarily their own biases, but their perceptions of the biases and beliefs of the people overseeing their practice and weighing how to negotiate that. And that sometimes results in inaction, which reinforces the perception that inaction is the answer, which perpetuates those biases. A more diverse provider and administrative base, people who understand complaints on a holistic level, are probably going to be more amicable to allowing effective treatment.
 

Seirende

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I think we could have a very interesting discussion on unconscious bias, which we all have to some degree or another. I'll try to dig up some literature on the topic.
 

DrParasite

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If anyone wants to read the actual study, it can be found here.

Draw your own conclusions
 

DrParasite

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And some other reading




 

Tigger

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And now to top it all off we are having to add additional shifts and do additional work so the triggered citizens in our area can have a public temper tantrum.
Which is in fact their right to do. Perhaps you lack some perspective on why people would choose to protest, which is in fact the correct term? Maybe disparaging people who feel they have no other way to speak up is an example of your own biases?
 

E tank

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If anyone wants to read the actual study, it can be found here.

Draw your own conclusions
This paper would never be published in a peer reviewed journal because just the group sampling is so skewed. The selection bias would be pretty hard to get around. Doesn't matter how large the sample groups are.
 

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