RocketMedic
Californian, Lost in Texas
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Saving The EMT-Basic: Why The White Patch Is Still Relevant
The EMT is a dinosaur in the world of health care, and the paramedic isn't far behind- but the alligator is a dinosaur too, and they're still thriving. Since the birth of EMS, we've positioned ourselves as the answer to the question of transporting the sick and injured to hospitals, and we've done a pretty good job at it. Today, though, we find ourselves rapidly reaching a crossroads. This latest government shutdown is showcasing just how fragile and vulnerable the money that supports our industry really is, and we are faced with a demographic time bomb- in the decades to come, there are going to be a lot more calls, a lot more sick people and a lot more demand for services placed on a provider base that is constricting, working with less money and expected to do more (does anyone reading this really believe that the Baby Boomers are going to adopt a Greatest Generation-type 'suffer in silence' mindset?) What we decide to do in the short term is going to define our industry in the future, and it's going to either insure we have a future or leave the business of field medicine wide-open for nurses.
People shout "education" from the rooftops; I'm one of them, and I'll keep saying it. Education is the key to individual and collective success- but it's not a panacea. There's only so much money to go around, and even in nations with true nationalized health-care systems, there's not enough money to go around. As much as I want to be paid and respected like RNs are, I can't help but look at the different staffing needs of EMS and suspect that we very well could end up with a situation like teachers face- low salaries due to limited funding and significant numbers needed while unable to counterbalance a massive cost to buy-in to teaching. Education is a long-term fix for a short-term disaster. So, with that in mind, what can we do as EMS professionals to keep ourselves relevant and profitable in the short term?
The EMT, in many systems, is a dead end from a financial standpoint- they can't provide patient care by contract, they're not trained "enough" to provide advanced care, and their low educational investments make them disposable employees if they get hurt or don't want to work their lives away. They're attractive simply because EMT is the contractually-obligated lowest member of the crew allowed. From a patient-care standpoint, they're quite valuable- but in an environment with limited funds, how do we justify keeping our partners on the trucks to politicians and communities who only see "ambulance drivers"? Don't believe me- look at New Zealand, where budget shortfalls leave paramedics working alone. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047887/)
So, how do we prove the white patch is still relevant? The answers to that are many, but here's a few.
1. Explore and Justify Different Service Models, and Make Investments In Yourself: Here's a mindblowing concept: In some states, EMTs are permitted to give narcotics with medical control, to start IVs, to interpret ECGs, to intubate, to call for flight teams as needed and even to transport patients without even the sight of a paramedic in the vast majority of cases. It is no exaggeration to say that the EMTs and AEMTs of Texas, New Mexico or Montana are better paramedics than many big-city paramedics. They do it more cheaply, more efficiently and with the same quality of care as expensive multi-paramedic operations in the majority of cases. How? They proved to their medical directors and their communities that they are capable of handling themselves at a higher standard than their patches would suggest. How did they do that? Individual training and education and a willingness to fulfill a need. You, as EMTs, as individuals, have to buy in educationally and add a few skills to your toolbox if you want to remain relevant. BLS and ILS trucks can work well for most systems. Heck, for that matter, our EMTs can do just as much in the way of Community Paramedicine as a seasoned paramedic can in terms of prevention and intelligence-gathering. Knowledge gaps can be rectified with reference guides, Google and a cell phone.
2. Get Rid of "emergent", ambulance drivers, BLS and ALS- and then use "ALS" "emergent" and triage appropriately:
EMTs and paramedics, this one is aimed squarely at you. Many patients don't need "ALS" at all, while others could certainly benefit from it but don't *need* it, and some certainly *do* need it. I find that a source of strife between EMTs and paramedics is the fear that EMTs will be found stupid or lazy for calling the paramedics for a 'mere' hip fracture, nausea control or for pain management- at my agency, this is managed by Paramedics Everywhere, while in other places, this is managed by simply guaranteeing that the patient will be treated inappropriately or to the minimum standards, not the maximum possible. Both of these answers are wrong- the first is unsustainable with anticipated future demands, the second is just unethical and wrong. The right answer to this is a mix of real EMD, strong EMT clinicans (potentially with increased scopes of practice to provide pain management and nausea relief) and paramedics used where appropriate with a culture that does not tolerate ambulance drivers or cot jockeys. This means involved leadership, real constructive criticism and QA/QI and even formalized follow-ups with patients.
Paramedics, don't be cot jockeys. If a BLS crew calls you, you should treat them like real subordinates- with respect, with consideration for what they've identified and with the patient's best interests in mind. In an *ideal* system, the sacrifices of the EMTs running themselves ragged with falls, low-priority MVCs and "sick" is keeping your well-educated *** from doing the same things. Trust me. It sucks. Show up, give some medications, and take care of your patient on the way in. That is your job.
3. "Subordinate vs Inferior": All too often, people treat partners as inferior, or perceive that treatment based on prior bias or misconception or simple ignorance. Yes, an EMT is subordinate to a paramedic, in the same way that a specialist is subordinate to a sergeant. Too many people mistake "subordinate" for "inferior", on both sides of the equation. My partner is my equal- but if we disagree, have different methodologies or different ideas, or different desires, then it's mine that are implemented. Not because I'm better, but because I'm a paramedic and he's an EMT, and is thus subordinate to me. That in no way makes him inferior to me.
In the military, similar situations arise on a daily basis. Good sergeants don't punish errors, they correct them and educate that young specialist or private so that they don't happen again. In EMS, though, we don't have that constructive leadership on a consistent scale. We get people screaming "paragod" or "experience" or some other mantra while they spray feces all around. Were that to happen in the military, you'd have more than a few hours of extra duty.
Don't think of that white patch as a limit, or as a club, or as a stair. Think of it as a rank badge. There's no reason you should be ashamed of it- but please don't let it limit your potential any more than a private in the Army is limited. A very wise Sergeant once told me that the art of leadership was not him making sure that I did my job, but training me to do my job well, his job, and to stand back and let me work while he worked on his own tasks and stepped in where he was needed. It worked well there- certainly better than other sergeants, where they tried to do everything and failed. Try it, folks. You'll see it's better.
-RM
The EMT is a dinosaur in the world of health care, and the paramedic isn't far behind- but the alligator is a dinosaur too, and they're still thriving. Since the birth of EMS, we've positioned ourselves as the answer to the question of transporting the sick and injured to hospitals, and we've done a pretty good job at it. Today, though, we find ourselves rapidly reaching a crossroads. This latest government shutdown is showcasing just how fragile and vulnerable the money that supports our industry really is, and we are faced with a demographic time bomb- in the decades to come, there are going to be a lot more calls, a lot more sick people and a lot more demand for services placed on a provider base that is constricting, working with less money and expected to do more (does anyone reading this really believe that the Baby Boomers are going to adopt a Greatest Generation-type 'suffer in silence' mindset?) What we decide to do in the short term is going to define our industry in the future, and it's going to either insure we have a future or leave the business of field medicine wide-open for nurses.
People shout "education" from the rooftops; I'm one of them, and I'll keep saying it. Education is the key to individual and collective success- but it's not a panacea. There's only so much money to go around, and even in nations with true nationalized health-care systems, there's not enough money to go around. As much as I want to be paid and respected like RNs are, I can't help but look at the different staffing needs of EMS and suspect that we very well could end up with a situation like teachers face- low salaries due to limited funding and significant numbers needed while unable to counterbalance a massive cost to buy-in to teaching. Education is a long-term fix for a short-term disaster. So, with that in mind, what can we do as EMS professionals to keep ourselves relevant and profitable in the short term?
The EMT, in many systems, is a dead end from a financial standpoint- they can't provide patient care by contract, they're not trained "enough" to provide advanced care, and their low educational investments make them disposable employees if they get hurt or don't want to work their lives away. They're attractive simply because EMT is the contractually-obligated lowest member of the crew allowed. From a patient-care standpoint, they're quite valuable- but in an environment with limited funds, how do we justify keeping our partners on the trucks to politicians and communities who only see "ambulance drivers"? Don't believe me- look at New Zealand, where budget shortfalls leave paramedics working alone. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047887/)
So, how do we prove the white patch is still relevant? The answers to that are many, but here's a few.
1. Explore and Justify Different Service Models, and Make Investments In Yourself: Here's a mindblowing concept: In some states, EMTs are permitted to give narcotics with medical control, to start IVs, to interpret ECGs, to intubate, to call for flight teams as needed and even to transport patients without even the sight of a paramedic in the vast majority of cases. It is no exaggeration to say that the EMTs and AEMTs of Texas, New Mexico or Montana are better paramedics than many big-city paramedics. They do it more cheaply, more efficiently and with the same quality of care as expensive multi-paramedic operations in the majority of cases. How? They proved to their medical directors and their communities that they are capable of handling themselves at a higher standard than their patches would suggest. How did they do that? Individual training and education and a willingness to fulfill a need. You, as EMTs, as individuals, have to buy in educationally and add a few skills to your toolbox if you want to remain relevant. BLS and ILS trucks can work well for most systems. Heck, for that matter, our EMTs can do just as much in the way of Community Paramedicine as a seasoned paramedic can in terms of prevention and intelligence-gathering. Knowledge gaps can be rectified with reference guides, Google and a cell phone.
2. Get Rid of "emergent", ambulance drivers, BLS and ALS- and then use "ALS" "emergent" and triage appropriately:
EMTs and paramedics, this one is aimed squarely at you. Many patients don't need "ALS" at all, while others could certainly benefit from it but don't *need* it, and some certainly *do* need it. I find that a source of strife between EMTs and paramedics is the fear that EMTs will be found stupid or lazy for calling the paramedics for a 'mere' hip fracture, nausea control or for pain management- at my agency, this is managed by Paramedics Everywhere, while in other places, this is managed by simply guaranteeing that the patient will be treated inappropriately or to the minimum standards, not the maximum possible. Both of these answers are wrong- the first is unsustainable with anticipated future demands, the second is just unethical and wrong. The right answer to this is a mix of real EMD, strong EMT clinicans (potentially with increased scopes of practice to provide pain management and nausea relief) and paramedics used where appropriate with a culture that does not tolerate ambulance drivers or cot jockeys. This means involved leadership, real constructive criticism and QA/QI and even formalized follow-ups with patients.
Paramedics, don't be cot jockeys. If a BLS crew calls you, you should treat them like real subordinates- with respect, with consideration for what they've identified and with the patient's best interests in mind. In an *ideal* system, the sacrifices of the EMTs running themselves ragged with falls, low-priority MVCs and "sick" is keeping your well-educated *** from doing the same things. Trust me. It sucks. Show up, give some medications, and take care of your patient on the way in. That is your job.
3. "Subordinate vs Inferior": All too often, people treat partners as inferior, or perceive that treatment based on prior bias or misconception or simple ignorance. Yes, an EMT is subordinate to a paramedic, in the same way that a specialist is subordinate to a sergeant. Too many people mistake "subordinate" for "inferior", on both sides of the equation. My partner is my equal- but if we disagree, have different methodologies or different ideas, or different desires, then it's mine that are implemented. Not because I'm better, but because I'm a paramedic and he's an EMT, and is thus subordinate to me. That in no way makes him inferior to me.
In the military, similar situations arise on a daily basis. Good sergeants don't punish errors, they correct them and educate that young specialist or private so that they don't happen again. In EMS, though, we don't have that constructive leadership on a consistent scale. We get people screaming "paragod" or "experience" or some other mantra while they spray feces all around. Were that to happen in the military, you'd have more than a few hours of extra duty.
Don't think of that white patch as a limit, or as a club, or as a stair. Think of it as a rank badge. There's no reason you should be ashamed of it- but please don't let it limit your potential any more than a private in the Army is limited. A very wise Sergeant once told me that the art of leadership was not him making sure that I did my job, but training me to do my job well, his job, and to stand back and let me work while he worked on his own tasks and stepped in where he was needed. It worked well there- certainly better than other sergeants, where they tried to do everything and failed. Try it, folks. You'll see it's better.
-RM
Well said