Category Archives: EMS 2.0

CA SB556 – The “He looked like them” Law

Special thanks to Mr Herrera for bringing this back to the front burner for me.

Just a quick reminder: The views on this website are mine and mine alone and not endorsed, reviewed or supported by my employer, co-workers, mother or hair dresser.

That being said,

SB 556 s a giant load of Gou shi.

“Oh my Happy…language…”

It is Gou shi.

Somehow the legislature is concerned that Erma Fishbiscuit is going to be confused when the nice men from the fire department arrive to take care of her, but then a completely different group of men arrive to take her into the hospital.  The uniforms may seem similar, but if she puts on her glasses she’ll see the patch on the sleeve does not say Fire Department, nor does the ambulance, nor does the bill she’ll get in a few weeks.

 

Apparently the law makers want to make sure Erma is aware that her local Fire Department has no interest in taking care of her by making sure the Fire Department employees wear a patch that clearly states “Government Employee.”

Oh, wait.

Scratch that.  Reverse it.

This bill would require uniforms that are similar, but only those not a government agency, to read “Not a Government Agency.”

Are we that stupid?

Don’t answer that.

 

This bill had obvious beginnings, that being to make sure the guy AT&T sub contracted my install to can be held liable when he screws up, but it was clearly hijacked by someone, likely a Fire Department Union or 2 unhappy with the ambulance contracts in their area.

Disclosure, I’m a union thug myself.

Requiring private contractors to wear a patch or insignia that states “Not a Government Agency” is just as stupid (and would be shot down in a heartbeat) as asking all municipal fire, police and EMS agencies to wear a large orange hat, designating them Government Agencies.

It’s good to know we solved the homeless problem and all the children can go to college free since we’re passing legislation to make contractors wear patches to tell the public what it already says on the side of their trucks.

 

This kind of crap makes me want to run for office just to slap them with the patch that says “Government Agency” and make them pay for it.

“That’s not fair, Happy” Yeah…I know…get it?

 

If you are for SB 556, I welcome your comments and ask that everyone commenting be respectful to one another, whether they be union thug or for profit people mover.

Response Time or Patient Outcomes – How do you measure your EMS system?

I know it’s been quite around these parts lately but a recent article caught my attention this morning.

High Performance EMS posted “Does Response Time Matter?” and it got me thinking.

The author states an example of a patient being “treated” by fellow citizens at an airport and having to wait 20 minutes for an ambulance to arrive.  The author goes on to describe how we need to arrive quickly to save the public from themselves.  After 30 years of telling them to call 911 for anything and convincing them that “seconds count!” what did we expect?  While I agree that a delayed response to certain patient presentations could result in an adverse outcome, that points out a glaring omission from the story.  Missing from the story is the patient outcome.  The outcome will allow us to marry all the data from the response to determine the answer to the author’s question in the headline.

The short answer is no, response times don’t matter.  And no, I don’t have to pee.  I have data that does not have any correlation between quality of treatment, outcome and response time.  From my perch here at the data hub of a quite busy EMS system we have been trying to determine the quality of our EMS system and we rarely look at response times.

Don’t get me wrong, we look and our Department statistician collects, quantifies, qualifies and reports to regulators the 90th percentile of all code 2 and code 3 calls to meet their requirements.  We report it, they receive it.  The document says nothing about the quality of care or patient outcome.  The reason being that we can not guarantee a positive patient outcome, but can measure when we left and when we arrived.  Imagine if we had to treat 90% of symptomatic asthmatics with oxygen within 5 minutes of arrival and document an improvement in condition.  Can your system guarantee that?  Why aren’t EMS systems measured by the quality of their care instead of the quality of their response?

Apply this metric to any other industry and it fails.  Industry is measured by their quality and efficiency, not the speed in which they complete their tasks.  So long as we only look at one metric with any regularity we will continue to shuffle ambulances 2 blocks at 5 minute intervals to meet an average instead of realizing just leaving them still would bring the same outcome.

That’s where I come in.  My Medical Director and I, unhappy with the lack of actual patient care quality metrics, created our own in an effort to determine the quality of care being provided.  We learned very quickly that our ambulances do not respond in a vacuum.  Each patient receives a call taker, dispatcher, first response, ambulance response, assessment, treatment and some get transported.  Once at hospital they receive a whole new level of care and review until they are finally sent home.  It is hard to argue that the time it took to get an ambulance from point A to B has an impact on this outcome without any review of the call taker’s coding of the call, the dispatcher’s assignment of the ambulance all the way to the destination hospital capabilities and location.

We can all sit at the Pratt Street Ale House in Baltimore and discuss short times that had a bad outcome and long times that had a good outcome, but the worst part of all of this discussion is that so few systems measure anything more than response time.

If you consider response time your metric of success you have already failed.  You have failed the patient who improves when you arrive “late” and discounting that response as a failure, yet trading high 5s when a 2 minute response yields a call to the Medical Examiner’s Office.

We all know the stories of companies staffing ghost cars near the end of the month to bring down the monthly response metric to meet guidelines.  It happens.  But I also wonder if that flood of ambulances to help more people had any other impact.

The complication in tracking outcomes is the relationship your agency has with local hospitals.  We may never have a seamless transfer of data but what we can do is pull data from the PCR to determine if the patient received the indicated treatments for the recorded chief complaint and observed complications.  By reviewing your policies and protocols as well as your patient demographics you can quickly spot your core performance indicators and design tools to track them.

It may be nice to know that we make our 90th percentile in 8 of 10 districts on a regular basis, but what if those 2 districts happen to have the highest number of cardiac arrest survivals to discharge?  Are they still a failure?

Widen your view to include more than how quick you can put the ambulance in park.  This goes far beyond the lights and sirens System Status Management debate and speaks to the core of the reason we’re out there to begin with:

To make someone’s bad day better

Delays can hurt, but not unless you look deeper into your system to find out if that is the case…or not.

999

Show me the Money

Friend of the blog Bill Carey posted on Facebook wondering why so many in EMS think that salary is the one thing holding us back.

Curious, question for EMS folks on FB: It appears, based on comments to various news stories in the past, that the greatest solution to all that ills EMS is greater pay. Respect is restored, working conditions and staffing improve and the general idea of professionalism is better. Fire-based, hospital-based, third service, doesn’t matter, just pay us more and the service will get better.
Really?

No, not really.

The same issues I had when I got the paid gig for $4.35/hr are here at my current gig where medics average $65,000 to start (according to indeed.com).

EMS in general is paid what the market allows and what we are worth.  Keep in mind that EMS does not require a degree and Paramedics can get licensed in as little as 1 year in some places.  If some kid walked into my office and told me he went to school for something for a year my first question would be “When are you going back to finish?”

Pay is a result of our goals, not our goal.

Increasing our education standards and proving our worth to the industry is step number one.  But of course the stumbling block to education is how to pay for it.

If you think the reason you are not treated like a Professional is the size of your paycheck I think I know where your priorities are.  If your first concern is that you don’t have access to enough education I’ll ask where you live and why you’re still there.

There are high paying EMS jobs out there, folks, I’ve had one for 10 years, but you have to be willing to put the effort into it.  No one is going to wander into the station or yard one day and say “You guys are great, here’s a raise.”  Your employer has no incentive to increase your compensation unless they desire a particular set of skills that bring that kind of salary.

EMTs are entry level and their compensation reflects it.

Paramedics have more responsibility and therefore more compensation.

A flight medic has even more responsibility, so more compensation.

A Firefighter/Paramedic has a different skills set, different compensation.

 

You get the salary you’re getting because that’s what you’re worth to your employer.  If you started off at $10 an hour, got your degree, teach on the side, and are still making $10 you need to talk to your employer about the increased value you can bring to the organization.  Maybe you’re in line for a promotion or reassignment with your increased education and experience.

It all comes back to education.  If you learn more, not only can you increase the care you can give to your patients, but you become a more responsible care giver and show your manager that you’re not just in the seat for a thrill, but to make a difference.  Folks like that make less errors, collect less complaints and are more likely to collect extensive billing and demographic information.

That makes you a keeper and worth more to them.  You increased your value.  That is the only way you will increase your compensation.

 

Let’s imagine that I’m wrong and simply snapping our fingers and giving you more money is the solution.

Now you make twice what you did yesterday.  Now what?  Now will you go back to school?  Teach?  Where is the added value we’re paying for?

The patients are the same, your rig is the same, your protocols haven’t changed and you haven’t changed.  There isn’t much we as EMTs and Paramedics can directly control but our own attitude and education are the easiest to improve in a short amount of time.

Just raising your pay won’t improve your attitude or the attitude of your co-workers.  It won’t help your manager see the worker bees from the cling ons and it surely won’t help your patients.

If you think you’re worth more to your organization than you’re being compensated, tell them, and get ready to pack.  The high paying jobs are out there, but you’ll likely be in a busier system and competing against higher education and higher motivated applicants for the extra money.

 

Case in point: me.

When I left my last job I was a Firefighter/Paramedic serving a suburban area working on both the Engine and Ambulance.  I was making just under $10 an hour on a 24 hour schedule.

When I got my degree in EMS and began teaching I knew I could reach out an look around for something better and have a good chance of landing it.

When I got hired in San Francisco as a Firefighter/Paramedic assigned to a 24 hour Ambulance I had tripled my salary.  Tripled.  But the cost of living was double and my old shifts of sleeping most nights turned into 32 run paramedic pinball sessions that I loved, but took their toll.

I moved 800 miles to get that gig and I have the broken down UHaul story to prove it.

You can get a high paying EMS job.  They exist, but you have to work for it.

What are you willing to do to prove your worth to EMS?

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Morpheus is fighting Neo!

In 1999 we were introduced the concept of the Matrix.  An electronic dreamland wherein machines of the future have enslaved human kind and keep us around as power sources.  Since the body can not survive without the mind, the machines have created an elaborate computer world that we all live in, oblivious to the truth.

A select few humans have discovered this fact and escaped, creating an underground resistance to fight the machines in the future and free human kind.

Spoiler Alert: I kind of doesn’t work.

Every time I hear someone in EMS complain about kidnapping, or having their chart blown up in court for all to see or some other urban legend of our Profession, I have to wonder what they would do if Morpheus arrived to show them the truth:

I picture Kelly Grayson sitting in a leather chair in some sweet shades and a fancy coat, holding out 2 pills to new EMTs.

You can take the blue pill, go along pretending this is all there is.  Backboards for everyone and NRBs at 15 liters per minute,  partners who torture with 14g catheters and refuse to tuck in their shirts, merit badge refreshers that rehash what we think we know and another conference class on how things used to be.

OR

You can take the red pill, and see the truth.

We are keeping you poorly educated and poorly paid because we need a steady stream of adrenaline junkies to replace you when you get burned out in 6 months.  You’re living in a dream world, new EMT, a dream world where the bare minimum is acceptable, even encouraged, and we make sure you’re just happy enough to accept it.

You go to work, collect billing information, treat from the cookbook, follow your patient’s every demand no matter how outrageous and it bothers you.

But what to do about it?

You’re here because you know something is wrong, but you can’t seem to put your finger on it.  No matter how many conferences you attend, magazines you read or managers you talk to, the answer seems to be the same:

“The future is now!”

But you don’t see it.  How can the future be here if it looks just like the last 30 years of guessing at science and pretending that taking them all and letting the MDs sort it out has ever worked?  When will you realize that “that’s the way we’ve always done it” is the last excuse of the desperate?

Take the blue pill and you’ll wake up tomorrow thinking your desire to improve was misguided, a waste, a dream.  You’ll strap up your boots and go to work, still wondering what is bothering you about what you do.

Take the red pill, stay with me, and see just how far we have to go.  Learn more about why, expand your horizons and seek out solutions.  I can show you the truth behind the lies, but you have to forget everything you know and trust me.

I offer only the truth.  Nothing more.

Morpheus: I imagine that right now you’re feeling a bit like Alice. Tumbling down the rabbit hole?
Neo: You could say that.
Morpheus: I can see it in your eyes. You have the look of a man who accepts what he sees because he’s expecting to wake up. Ironically, this is not far from the truth. Do you believe in fate, Neo?
Neo: No.
Morpheus: Why not?
Neo: ‘Cause I don’t like the idea that I’m not in control of my life.
Morpheus: I know exactly what you mean. Let me tell you why you’re here. You’re here because you know something. What you know, you can’t explain. But you feel it. You felt it your entire life. That there’s something wrong with the world. You don’t know what it is, but it’s there. Like a splinter in your mind — driving you mad. It is this feeling that has brought you to me. Do you know what I’m talking about?
Neo: The Matrix?
Morpheus: Do you want to know what it is?
(Neo nods his head.)
Morpheus: The Matrix is everywhere, it is all around us. Even now, in this very room. You can see it when you look out your window, or when you turn on your television. You can feel it when you go to work, or when go to church or when you pay your taxes. It is the world that has been pulled over your eyes to blind you from the truth.
Neo: What truth?
Morpheus: That you are a slave, Neo. Like everyone else, you were born into bondage, born inside a prison that you cannot smell, taste, or touch. A prison for your mind. (long pause, sighs) Unfortunately, no one can be told what the Matrix is. You have to see it for yourself. This is your last chance. After this, there is no turning back.
(In his left hand, Morpheus shows a blue pill.)
Morpheus: You take the blue pill and the story ends. You wake in your bed and believe whatever you want to believe. (a red pill is shown in his other hand) You take the red pill and you stay in Wonderland and I show you how deep the rabbit-hole goes.

 

It should be noted that many Matrix fans believe that the “real world” and Zion are also parts of the Matrix used to control the radical element and that the machines have anticipated their desire to rebel.

EMS doesn’t need a Neo to come and save us, or even a Morpheus to show us the way to the Oracle to hear what we need to hear.  But what we do need to do is wake up, look around and stop taking half truths and scare tactics as solutions for our patients.

Which will it be?  The red?  Or the blue?

What vs Why – Ramsay vs Hunter

In the 1995 submarine film Crimson Tide Gene Hackman plays experienced Navy Captain Frank Ramsay assigned to the nuclear missile submarine Alabama.  Playing opposite him is the younger, up and coming Lieutenant Commander Ron Hunter played by Denzel Washington.

I enjoy the film and constantly find myself watching the battle of wits between “Old School” and “New School” often wondering who will win the upper hand.

Ramsay is from the Old School of Navy warfare and he knows it.  Hunter is the new Executive Officer (XO) on the boat and one night at dinner the conversation turns to the glaring difference in style between old and new.  Ramsay mentions that the Navy doesn’t want him complicated, but simple.  With just a hint of sarcasm the young Hunter replies that Ramsay has the Navy fooled, indicating that he is indeed more complicated than he’d like to let on.

“Be careful there, Mr. Hunter. It’s all I’ve got to rely on, being a simple-minded son of a bitch. Rickover gave me my command, a checklist, a target and a button to push. All I gotta know is how to push it, they tell me when. They seem to want you to know why.”

The conversation continues to explore the reasons for war and the different views on the subject which I won’t go into here, but it’s a great back and forth.

“They seem to want you to know why” sticks in my head though.

I see this conversation all the time in Fire Stations and Hospital ambulance bays.  The salty old anchor who is good at what they do questions the up and coming schooled rookie, assured that simply knowing what to do is better than worrying about why.  The rookie, educated and trained far beyond the salty anchor lacks experience and needs to find a balance.

Cut off from command, their last message was cryptic and incomplete.  Nuclear war is feared and the two schools are pitted against one another.  Old school sees it as an order to fire while the new school sees it as a chance to get more information.  The What vs the Why.  Ramsay orders a launch, Hunter refuses and the battle of wits has begun.  Old school bends the rules to meet their ends and new school tries to outwit him at every turn.

Throughout Crimson Tide we see a struggle between old school and new school during a crisis situation as each of the leads falls back to their comfort zones for support.  Ramsay leans on loyalty while Hunter seeks out new members to join him in opposing the Captain’s actions.

Don’t get me wrong, knowing what to do is important, but I think you know I’m a bigger fan of knowing Why.

One of my instructors used to say “I can teach a cat to intubate, but I can’t teach him when not to.”  He was the same instructor that, when faced with a scenario in lab and someone would initiate a treatment he would always ask “Why?”

BP is low, start a  line.

“Why does their blood pressure bother you?”

We’re here to fight.

“Why do we fight wars?”

Pulse is 50, hand me the atropine.

“Why is Atropine indicated here and why will giving it make things worse?”

I don’t think this is a good idea.

“Why can’t you just do what you’re told?”

 

In the end of the film, we discover that Why wins the day as the information was incomplete.  Had What been victorious a bad decision would have been flawlessly executed.  You can perfectly intubate every time, I get it, you’re a salty dog, but the last 4 you got were completely unnecessary.

 

Let me show you Why.

 

Which one are you?

 

Paramedic – A look back at the first 100 years – Part III

Now that the solar flares have passed and we’re all back topside we can continue on our jaunt through the history books looking back at the first 100 years since Paramedics were born of necessity and grew into the most valued public service since the Post Office was reinstated.

Today we look at the early use of the pre-cortex for Paramedics of yesteryear to check their work with Physicians.

 

Online Medical Control

Before the Cortex people accessed a maze of sites with conflicting information, often having to enter queries using digit tabs called “keyboards” which allowed them to access information.  From my research I have discovered that early Paramedics were rarely trusted to make decisions on their own and would access online medical control.

Since the Paramedic’s searches were based on their own impressions of what was happening, it was very easy for them to access the information they needed for the proper treatment of their patients.  It was not the same as today, where Paramedics are trained to act in all situations, but instead was a way for our lesser educated predecessors to ask for help on difficult cases.

This was also referred to as “WebMD” and was accessible from any screen in any community.  Before screens contact was made via telephone line or by radio.  I know it seems odd to call a WebMD for Online Medical Control without them being able to see the patient but apparently it was done quite often.  Some systems were very strict and even required Online Control for some medications.

You see, before Paramedicine was recognized as a specialization it was often relegated to those who could not afford to attend Medical School but still wanted to make a difference.  This WebMD allowed them to be trained quickly and work for far less than their skills were worth to the greater medical community.

After the influenza their value was recognized but up until then Paramedics still accessed the world web when needed, not unlike a wave consult for surgical consults of decades past.

It was a good tool for the time but seems to have held Paramedicine back in some communities for reasons I can’t discover.

 

Next time we’ll answer one of the biggest mysteries of early Paramedicine:  Was it really done by the Firemen?

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A new kind of intern

For the last two Tuesdays I have had an intern.

I can hear you now, “That silly Happy, he has a desk job, how can he have an intern?”

Well, a local High School has expanded and offered an EMS Intern position.  One of the local Rescue Captains has assisted in designing the program which will give this student an inside look at not just field time, but supervisor time, administration time, radio time and even a few days with the regulators (Remind me to ask her to ask about proof spine boards are a good idea.)

I am proud to announce she was officially bored out of her skull in the CQI office.  What we do can be distilled down to the high school level, but the finer points of QA (stop laughing already) can be lost.

“We apply the rules, regulations, policies and protocols to each chart and determine if variations warrant review, coaching, counseling or reprimand.  And after completing those reviews we analyze the results to determine trends and act on them.”

She was unimpressed (Seriously? Stop laughing.)

So we read a narrative I was reviewing.  It went a little something like this:

“Police activated EMS for man defecating on sidewalk.  Male present alert and oriented, steady gait near pile of human feces.  Male has no chief complaint and has no signs of traumatic injury.  Male states “Just cite me and go away” without slurred speech.  Male does not give consent to treat or to assess vital signs, threatens to pick up and forcibly relocate feces, EMS agrees male may leave area under own power.”

“Why did the cops call if he wasn’t hurt?” She asked.

“We’re working on that, but I expect your generation to get that sorted out for good.”

 

She had a chance to meet the Chief of EMS and talk to him a bit about what it means to be a Paramedic these days and looking forward.  He is of the same mindset as me, that we make bad days better and go home safe to our families who will never know the truth of what we’ve been through.

I told her that the gauge of a good EMS leader is someone who, when asked if they would go back to an ambulance answers “yes” without the slightest of hesitation.  You can be away from the ambulance for only so long I have learned and the farther away, the more you miss it.

 

Next Tuesday is her last day in the Administration track and we’ll stop by the fleet yard and let her observe a World Class System deploy to chaos.

 

Paramedic – A Look back at the First 100 Years – Part 1

2066.  100 years since the White Paper that solidified what some communities were already learning:  Paramedics were needed to help in communities that had no doctors.  We were born of trauma.  Accidental death was our crib and cardiac arrest our playroom.  In our adulthood we expanded into the community and dealt with chronic health issues.  Now reaching 100 years young there is so much farther we can go.  But to know where you’re going, you need to know where you’ve been.

It’s easy to forget where we came from.  Not just back to the ancient times when drivers had wagons and horses, or when the hearses (I still can’t believe we buried our dead) began to treat people, but at the decades that propelled Paramedicine into the respected Profession we practice today.

In this series I’ll be covering all manner of advancement in care, organization, education and funding, but I wanted to start off by clearing up some myths about the early days of Paramedics.  These are all 100% accurate, as I have referenced texts from the time.

Let’s start with one of the Urban Legends of Paramedicine:

Chemical reversal of death - It is true.  It can now be confirmed, based on texts from the day, that Paramedics (Often called EMTs back then) would inject patients suffering from cardiac arrest with cardiotoxic chemicals that they thought would mimic the heart tissue’s natural functions.  There were no balloon pumps back then and hypothermia had yet to become rapid onset using the sheaths.  Although they did begin to cool patients using cold packs and cold venous injections (transdermal fluids were decades away), many patients were likely inadvertently killed as a result of this practice.  Some research was recovered that showed dismal success rates, but it wasn’t until the H6N3 epidemic in 2023, when stockpiles of cardiotoxins were depleted and survival did not worsen, that the industry finally took notice and eliminated their use entirely.

It was the Paramedics that rose up during the epidemic that overwhelmed the hospitals of the day, which quickly became incubators for the rapidly mutating infection.  It was the mobility of the Paramedics that allowed for continued care when the hospitals shut down for months to be disinfected.

Combined with AEDs (ShockDocks) installed as frequently as fire extinguishers survival from cardiac arrest improved.  It was not the hospitals that led the change, but the Paramedics who fought for common sense technology in the community.  When MRI and Xray were still not in the patient’s home, they stood up and demanded change.

It is worrisome that it took something drastic for Paramedics to look at their own practices for efficacy instead of demanding proof before using it that it would do no harm.

 

Next time: A lead on the curious boards used to apparently keep drivers from falling into traffic.

Ambulance Facility Must Haves

Many an article looks at ambulance design, Paramedic training, policies and protocols but I’ve been wrestling with a different kind of barrier to quality: The Fleet Yard.

 

More specifically, I was wondering what your must have list is for an ambulance deployment center.

 

Is it indoors, well lit, vending machines, training on site, locker rooms, showers, supply techs, drive through ambulance wash…

Here’s my must haves if I could build a brand new facility:

  • Drive through restocking and shift change
  • Onsite mechanical repair
  • Onsite scheduling, CQI and training
  • Indoor secured fleet and employee parking
  • Vehicle Service Techs for restocking
  • In-unit mobile data gateway repair (after I get them installed that is)
  • Crew lounge
  • Locker rooms with full showers
  • Gym

Let me know what your must haves are, maybe you’re thinking of something I’m not.

 

The hour is late

Recently a close friend asked why we even try.  Why do we try so hard to achieve all the goals we have been chasing?  Who cares?  Isn’t there someone else who can fill in what we’re doing better?

No.

No there isn’t.

If there was something better that could be done, we’d be doing it.

This forum used to be updated every few days, some days even multiple times a day.  My duties have consumed my time, heart and vision.  Previous posts about not being able to change the system have turned into meetings that are changing the system.  For every crazy story I try to tell, I read an actual chart that mirrors my edited version and the tale can’t be told.

We’re on the verge of some major opportunities in my system and that seems to be monopolizing my time.

Go figure.

13 months ago my priorities changed and this therapy experiment has suffered.  It was created for one purpose and one purpose only and that was to serve as a pressure release valve.

Boy did it ever.

But the pressure might be too high this time around.  The troubles aren’t with those in charge of the system, or the system itself, but within myself.  My dreams of an EMS 2.0 world were destroyed by regulators, bureaucrats and the realities of a for profit system only to be rebuilt by a single EMT doing the right thing despite our policies to the contrary.  Our late night discussions in Baltimore, Vegas, Houston and other places all build into a mural of a future for our Profession only to be sidelined by technical issues and personnel conflicts.

We were dreamers.  We looked at a future that was built around quality patient care, not realizing the first question would be “how are you going to pay for all that?”

I checked…the Police Department has yet to post a profit.

It isn’t an uphill battle we in EMS are fighting, it’s an all out war.  There are those who wish to take over, give up, concede, demand even take a seat on the fence and wait to see who wins to declare their allegiances.  We can get frustrated, rant, moan and complain or we can give 100% to the one thing that matters:

 

The patient.

 

My posts may slow, my twitter may stagnate, but only because I have a chance to make a difference for more patients and I’m taking it.

Join me?

 

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