Sunday, November 23

Working on the Holiday - A poem

So you've got to work the holidays, or your boss will get real mad?

You work in a big box store in town, and your schedule makes you sad?

Well let me tell you another story, of some folks who just like you,

are working on the holiday, so that others do not have to.

We are your firefighters, your medics, your cops,

your nurses and doctors ready to assist,

just like every other day, not just December 25th.

We'd like to teach you something you'll eventually figure out,

a holiday is just a number, there's no need to pout.

Turkey tastes delicious on November 29th,

and sometimes we celebrate Christmas on the 26th, at night.

Your place was open last year and the year before,

on the day so suddenly special you want to blame the store.

So for those of you who complain about working this holiday,

remember the others who are always working regardless of the day.

You won't have to work the holiday when you get a better gig,

but if you're lucky, you will, cause you'll be with us in the rig.



Monday, November 17

Community Paramedicine doesn't belong in EMS

Community Paramedicine, or what some would rather call Integrated Healthcare, is a fantastic concept.  Why not take basic medicine and evaluation skills to the patient recently recovering from a procedure instead of making them visit the MD's office?

Why not follow up with Mrs Jones on how her medications are doing?

Why not have a Paramedic check in on Mr Thompson and his blood sugar levels?

My first paying gig in EMS was for a system that did just this.  We visited our list of clients based on the schedule and checked their blood sugar, blood pressure, medications and checked the fridge for food.  I hated it.  I hated it because it wasn't what 18 year old me wanted to be doing.  I didn't see the value in the program until I was about to finish my employ there and noticed we never ran a 911 call on any of our home visit regulars.  We weren't providing Emergency Medical Services (EMS), we were doing something completely different.  Call it by any name you like, but don't call it EMS.

Today I'm a huge supporter of decreasing the demand on 911 by focusing on reducing the number of people who call.  One of the proven tools used to combat 911 calls is making people healthier before they need 911.

Community Paramedicine is just the thing each and every community in America can use to reach out to a niche that needs to be addressed.

When I was in England all those years ago Paramedics with only 1 year experience were out on their own making recommendations, referrals and taking people directly to what they needed, not just a 2 person cot van to an ER (Or AE for those who favourite that term.)

The concepts have been proven over and over again and some systems are even carving out revenue streams to make it profitable or, at least, not at cost.

I applaud their efforts and if the opportunity ever comes along for me to get involved...

...I'll pass.

In my opinion Community Paramedicine is too important to be trusted to the 911 crowd.  We need folks more interested in sitting and talking than squeezing a few home visits in between calls for service.  Some systems have adapted schedules and providers to respond only on the Community cars and that's great, but a greater separation is needed.

Yes, I'm advocating splitting EMS even further than we are now.  A split that will allow this new sub specialty to thrive.

Community Paramedicine needs to be a specialty, a half brother, not a spin off hoping to get picked up for a second season.

It will not succeed if it is tied to the chaos that is 911 for profit and must succeed if 911 for profit has any chance of surviving another 10 years.  We're approaching a cross roads to possibly finally squeeze our little patient care machine into the main stream of medical professionals.  Do we want to squander that opportunity by having Community Paramedicine as a side project of EMS or as a full fledged community service independent of the lights and sirens?

I know 18 year old me had a different reason for having this opinion, but the opinion remains:  911 and community care shouldn't mix.  They should each focus on their strengths and excel at the service they provide the community instead of stretching us so thin only our merit badge classes hold us above water.

Sunday, November 16

Taylor Swift inspires new EMS billing model

I've been reading in the papers lately that Taylor Swift and Spotify have been going back and forth about royalties for her songs playing on the streaming music site.

According to sources, she was paid less than $500,000 for 12 months of her songs playing on the site.

My first two words were Boo and Hoo.

Then I looked at the feed of a friend of mine who is a musician.  They have a fair argument in that the way the industry is arranged you get a small amount for creating the music (writers, musicians, performers) then more the more the piece is performed.  It makes sense on a certain level, but the model is clearly outdated.  Before it can be changed, the industry should realize that fewer and fewer of us listen to terrestrial radio (where their songs are actually placed at cost, not at profit) and more of us are streaming music using spotify and Pandora like apps.

I start with a band I like, then it introduces me to other bands I may like as well.  Then I buy their albums, but not in a store (that used to take as much as 30% of the 19.99 for the long box), I pay 99 cents per song on itunes at no cost to the production company.

This line of thought brought me back to EMS.  Let's apply the music industry reimbursement model to what we do:

First off, you'll be required to create unique treatment models and protocols.  Then you'll be paid a small amount for actually providing the care requested. (no real change there, right?)

Now here's the BIG difference:

You get 1% of your patient's income.  For life.

Are you motivated to provide quality care now?  Will you go to any level to ensure high quality care in any location in the world?

How quickly will our industry adapt to this new model?  Suddenly the more calls we run the more we can possibly make.  Will we focus on younger patients?  Will we ignore certain neighborhoods unlikely to yield incomes worth our efforts?  I think you know the answer to that.


While I still don't feel bad for Taylor Swift only making half a million a year on 1 web site for something she did long ago I also know she wasn't in there alone and the folks who were aren't necessarily the ones out on tour or behind her on SNL making money.  They were brought in for a day to play saxophone, record a piano solo or sing backup with the promise of a cut of the plays in the future.

Although I think billing EMS based on future income would see a HUGE shift in our comfort with pediatric patients.  Don't you?

Thursday, November 6

The 3 Real Reasons EMS isn't Ready to Refuse Care

Sean Eddy from Medic Madness, and fellow Uniform Stories contributor, has a new post up titled "3 Reasons EMS isn't ready to refuse care."

Go have a read, then come back for my comments.

Well, you're either ready to storm Sean's gates with your sharpened pitchfork or ready to defend him from what I've got to say on the subject.

Sean brings up some great issues that have been bouncing around EMS circles for decades.  With the recent introduction of Community Paramedicine and the concept that we can, gasp, leave people at home in certain situations, EMS providers are looking to build on the outdated "Transport them all and let the ED sort it out" mentality of the 1970s.

Sean's 3 reasons are certainly worth discussion but I think he was very careful to sidestep the elephants in the room.

l'll address Sean's reasons 1 by 1, then give you the 3 real reasons we're not refusing care.

Sean's Reason #1 We're not trained for it.

I'll agree with Sean here on a handful of cases.  I would argue that leaving a hyperventilating patient at home simply telling them "It's just anxiety" without addressing the symptoms we aren't ready for, nor should we be ready for.  However, this skips over the other 99% of our calls.  When a person has an injury or illness (or nothing assessed) and asks us "Do you think I need to go?" we should not be bullied into transporting by a management who only gets paid if the wheels turn and a nurse signs the chart.  Honestly answering that patient's question and giving them the information they need to seek the care the need should be job #1.  We are trained for that.

Sean's Reason #2 No Legal Protection

This is one of the urban legends of respond not convey, that somehow, somewhere, we're simply going to pull up, roll down the window, tell the person to just go to the ED and drive away.

There is not added liability in obtaining a refusal for a stubbed toe after telling the person that they don't need to go in an ambulance than there is in obtaining a refusal after telling them they should.  Zero.  It is simply changing the amount of accurate information available for the patient to make an informed decision regarding their are.

Sean's Reason #3 - We aren't designed to be the end point in care

Sean brings up an interesting point that we are not meant to be the definitive treatment for patients, that that is only done by MDs.  Then I would call into question each and every refusal of service ever collected in the history of EMS.  We should be, and currently are, the end point when necessary.  Again, we're not talking about chest pain, stroke, abdominal pain of unknown etiology, those patients are all obviously in need of evaluation and we are not their end point.  For the finger smashed in the door of the car we are also not the end point in care but that is no reason to REQUIRE ambulance transport to an Emergency Department.  I can't fix the finger, surely we can agree, but there is nothing I can do beyond splinting and supportive care.  In addition now we're sending an urgent care level patient to an ED, grossly over triaging "just to be safe."


Sean is a friend and don't take my comments about his concepts as disagreeing with him.  He and I have discussed this topic repeatedly, as many of us have, and it is of course far easier to comment on ideas than come up with them.  But we all need to be realistic about the REAL reasons EMS is not ready to refuse care.

Real Reason #1 - There's no profit in it

Oh, there's reduced cost in it, but no profit.  Spending 30 minutes on scene for a refusal is not nearly as lucrative as a 30 minute transport.  There is no increased liability, no increased training required, no fancy advanced classes or licenses, we just have to do what is right and allow the patient to make good decisions and seek out appropriate care in the community.  But so long as insurance only covers transport, it won't happen.

Real Reason #2 - We don't understand liability

Leaving Erma Fishbiscuit at home isn't the problem, it's transporting her for no reason to an ED for no reason "Just to be safe" that is the liability.  We remove needed resources from the system to satisfy decades of urban legends from the anchors about so and so who broke the rules and left someone home to die, but never about how no rigs were available for Mr Johnson yesterday.  If the rules were broken and something bad happened, it isn't the rule that is the problem.  We shouldn't be scared about letting patients make decisions.  We inform, they decide, we do our best to get them what they need, we complete a chart and go away.  Just like we do now.

Real Reason #3 - Adrenaline and turnover

No EMT wants to sit in Erma's house for 30 minutes making sure she knows where her medications are and when they should be taken.  No Paramedic wants to sit with Mr and Mrs Jones and explain how their daughter's nebulizer works.  They'd rather hit the lights and sirens, break hearts, save lives and take'em all and let the Doctor's sort them out, after all "We don't diagnose."


EMS is having a real problem taking itself seriously recently.  I applaud Sean for making his list and putting it out in the public.  We have a decision to make in the very near future and that relates to the future of EMS and I see it will divide us even further and I think it's a good thing.

Yes, I said dividing EMS is a good thing.  More to follow.


Monday, November 3

Tinglings of Inadequacy

In Paramedic School there were three know-it-alls in the back row.  Every Paramedic class had them.

They asked questions with 3 minutes left in class, always challenged the instructors for more challenging scenarios and seemed to always hit the airway lab right when everyone else broke for lunch.

They challenged test questions, the sequencing of interventions in answers and were eventually separated for testing, you know, "Just in case they're cheating."

They had their own study group, volunteered to teach the EMT and EMT-I classes when instructors needed a break.  All 3 of them stood together and graduated with their Bachelor's of Science in EMS on the same day.

Then they drifted apart.

Weddings, kids, careers.

Then one of them got into Medical School.  He sat to my right and is now a full fledged MD.

The kid to my left we called Doogie because he was young and smart.  I just found out today he will be completing Nurse Practitioner school in December.

My 2 best friends throughout Paramedic School and our clinical rotations, the guys I laughed with, cried with, broke bread with and, come to think of it, literally bled with, have achieved so much and I couldn't be prouder of either of them.

Dr Ian Medoro and soon to be NP Josh Kinnunen were my best friends for many years.  And even though life pulled us in different directions I am beside myself in admiration to the both of you.  We all had the same start, the same passion for quality patient care and have landed in three drastically different places.  The 2 of you seeking out more education and fitting into another form of care while I'm still in the field with my name on my shirt.

Those days listening to Larry and Kyle inspire us to do better, the anatomy lectures that seemed never ending, the waitress at the Applebees on bottomless chicken strip basket Fridays (I think we put her through grad school) will always be some of my best memories.


So congrats Doogie on making NP and congrats Ian on making MD!  The guy in the middle is happy where his is and proud of where he's been.

Sunday, November 2

Add Aiden Riebel to your Duty Roster

Young Aiden Reibel was brought to my attention through the Facebook.  He is a fan of the fire service in New Jersey and suffering from health issues that keep him from his dream: Riding Along at the local Fire Department.

Amidst the patch grabbers and beggars across facebook, Aiden's supporters caught my eye when they simply asked me to add Aiden to the roster for the day.

It wasn't a request for me to be with Aiden, but for Aiden to see he was with me.

I was moved.

I erased my name off the board at House 3 and added his name as the Rescue Captain (RC) for the Airport and sent the picture into the facebook page.  There he was with me as well as with a handful of other Departments from across the nation.

Each and every post was a photo of Aiden's name on the roster board, gear, helmet or rig.  Aiden was riding along at FDNY Battalion 9, with me in San Francisco, and a host of other agencies even an ambulance in Spain and a wildland crew in Australia.  Each post included a phrase along the lines of "You're with us" instead of the usual "We're with you" you see so often.

While Aiden is indeed accepting patches, the more powerful message is that even though he is too sick to ride along like he wants, his name is being spoken across the world in firehouses, ambulance yards and volunteer musters.

And to me that is far more powerful than any patch.

Aiden was with me for 2 days last week and thinking about having him along made me think about my own health and that of my family.

Your drill for today is to put Aiden's name on your roster, rig or gear and let him ride along in spirit for the day.  Then shoot a pic and share it with Aiden's page on FB.


It is literally the least you can do and will mean the world for a sick kid and will do wonders for your soul.

Trust me.