Something old for a new system

“EMS Medical Directors are a box of chocolates.  You never know what you’ll get.”

Forrest Gump, Paramedic 

In light of the recent criminal trial against two Paramedics, there are plenty of people calling for new levels of accountability for our clinical practices, and everything else.  I’m not a fan of solving problems with new laws, so I generally don’t look at the State EMS department to regulate the minutiae about how we do our jobs. 

But, if we don’t do something, someone will… and we probably won’t like it.

(Go check out the recent EMS news from Milwaukee)

We do have a solution, already in place.  The EMS Medical Director.

And I’m not talking about “progressive protocols”; I’m talking about system accountability, and improvement.

Let’s first set the stage with the industry’s expectations:

From NAEMSP: “The process of credentialing specifically involves the attestation by an organization's EMS physician medical director that the EMS provider possesses required competencies in the domains of cognitive, affective, and psychomotor abilities.”

and       

“The EMS physician medical director must have final authority and accountability for credentialing of EMS providers providing care under their oversight. While the physician medical director may delegate evaluation of an EMS provider's competencies, the EMS physician medical director must be actively involved in the EMS organization's clinical credentialing process.

Credentialing involves at a minimum: (1) demonstration of sufficient cognitive knowledge; (2) demonstration of mature, responsible affective ability; (3) demonstration of a command of all involved psychomotor skills; and (4) integrating the three previous domains in the application of critical thinking in the provision of clinical care for all acuities of patients that may be reasonably encountered in the jurisdictionally relevant practice of EMS medicine.”   (Clinical credentialing of EMS providers position paper, 2017)

There. There’s your standard if you’re the Medical Director.  You’re the one authorizing people to go out to save lives and cheat death.  Drugs aren’t pushed, electricity isn’t delivered, blinky lights don’t flash without your approval. That’s your job.  Defer or do. 

We know a newly-minted Provider is minimally competent.  We know that a new EMT might have never seen an actual sick person during their program, due to clinical restrictions three years after COVID.  We know a new Paramedic might have only intubated patients in the OR.  So, what are we doing about this known problem? 

Annual skills lab? Send them through an alphabet course? Rely on a refresher?

Because most Medical Directors fill the role part-time, they don’t have much of a choice but to defer and delegate.  And, in many cases, the Medical Director has no EMS experience; some may not even have Emergency experience—they’re the friendly local primary care physician or podiatrist friend of the CEO/Chief.  It’s easy for them to listen to the agency to tell them the standard and to simply take a back seat altogether; one of “The Eagles” coined the term “Milk carton medical director” (pictures of missing children used to be printed on milk cartons):  If your Medical Director hasn’t come to your station to review runs, hasn’t updated protocols (or just copies another agency’s), or does nothing more than collect a check from the agency, you don’t have a Medical Director—you have an expensive signature.

So, what do we need to do to improve?

First, acknowledge the problem.  Acknowledge that a hands-off approach isn’t what we need.  It isn’t what our community needs, or deserves. Break out the coffee and the notepads—it’s time to talk.

Second, understand the reality.  Go to where the work is being done.  Sit in new hire orientation.  Talk and ride out with the FTOs.  Talk with the EMT and Paramedic education programs.  Talk with the new hires about their experience, fears, expectations.  Bring skills and knowledge into the light.

Third, start doing something.  Break out the Registry/State skill sheets and use those as the bottom basement standard.  Set Fred the Head on the station table and have people go through the checkboxes.  Grab a EMR/PCR/runsheet and present the run to a crew to see how they’d handle it (assessment, interventions, sick/not sick, ECG, etc.).

Fourth, land on a larger need and start developing solutions. Spend the time and resources to test and shape something that works for your agency and community.

Medical Directors: If you don’t understand your role and responsibilities, talk to someone who can explain them to you (read NAEMSP’s position paper).  If you don’t set the standard, the agency will.  If you can’t do all the work yourself, get an assistant who can help. 

Agencies: Don’t settle for an absentee Medical Director.  If you can’t hire a new one who will set a high bar for you, set the bar yourself. Bonus, you’ll be more popular with the community and new employees.

Providers: If no one is holding your performance accountable, hold yourself accountable.  Go to courses that raise your knowledge and skills.  Talk to people in the hospital and go to specialty units.  Follow #FOAMEMS.

The brown stuff runs downhill, and you’re at the bottom.

At the end of the day, if we point fingers, realize there are three pointing backward.  We cannot say, “It was their responsibility.” 

Our communities deserve excellence. 

Our family members deserve excellence. 

Our Providers deserve a system where they can shine. 

Our leaders deserve opportunities to develop their people. 

Our industry deserves highly competent Providers, not ambulance drivers.

Nutty, salty, dense, cheap, exquisite. 

Chocolate or Medical Director?

*On one extreme is the absent Medical Director.  On the other is the one who is tied into operational and HR things.  Bad move. The Medical Director must be wholly focused on clinical things.  I had an agency ask me how to convince their Medical Director to suspend privileges of one of their Paramedics so they could fire him for non-clinical-related problems.  Wrong move. 

Do know there is existing case law in the event employment issues happen as a result of losing clinical privileges.