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?

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?

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?

In a follow up to the Angry Captain in Miami-Dade I got to wondering why Captain Smart had not already been fired.  Millions of people have now seen this video of Captain Smart wrongly trying to bully a citizen into not filming a helicopter operation.

He was wrong in intention, in the law, in Operations…I’ll even go so far as to say the polo shirts they wear leave a lot to be desired, but, it was at least clean and tucked in.  He raised his voice, yelled, threatened to call the police, called the police, all the while the patient was not being transferred.  But they run 3 man rigs there…so 2 plus the helo crew likely means the patient was being well looked out for.

So let’s get to the giant pink double standard in the room.

Let’s say this video was posted onto a local Miami-Dade Facebook page in a universe where Captain Smart stays in that odd looking ambulance and transfers the patient without confronting the person filming.  All goes fine and they later drive away.

Now Captain Smart gets home and sees the video.

He types his interaction with the person filming into the comments section.  Word. For. Word.

I think we can all agree Captain Smart would have already been suspended and a blanket no social media policy would be in place in Miami-Dade.

So why the double standard?

I think it is because Departments have yet to realize that social media is just the tool bad employees use to do bad things.  Captain Smart didn’t need social media to make his agency look the fool, he did that on his own.  He just had the unfortunate experience of doing it in front of 2 cameras.

Facebook is not your enemy Mr and Mrs Fire Department, your bad eggs are.

Captain Smart may be an accomplished firefighter/Paramedic/Company Officer but will forever be remembered for losing his cool with a kid with a camera that one day the helicopter landed.

Folks, we are being filmed everywhere we go.  Generation Y seems to understand that, the boomers are having a little more trouble with it I think.  Having even more trouble with it are the folks in the gap, those in their late 40s and early 50s.  For whatever reason it’s this population that seems to adopt a black out mentality when it comes to social media and sharing membership in the fire service.  There are exceptions to every rule, I’ve met quite a few right here within the walls of social media.  Trouble is, most of the administration of the fire and EMS services today are in this socialphobic bubble where anyone who posts a pic of themselves in an FD T-shirt on facebook is out to ruin the good image of the Department.

Just look at Captain Smart.  He didn’t need social media to screw up, he did that all on his own, but will likely not even get a day on the beach judging by his Department’s initial response hiding behind scene safety.

Your crews wear polo shirts…scene safety?  Nice try, shake the magic 8 ball again Miami-Dade.

Just remember that had he done it anywhere else but in the face of a citizen, at an emergency scene with patient care still happening and captured on camera for the world to see, it’s a bad thing.  Seriously?

Surely you’ve all seen Statter911 and FireLaw’s take on the Miami Dade Angry Captain for shouting at the public for…well…I can’t figure out why.  Dude wants to shoot video in public, dude can.  Dude isn’t covered by HIPAA.  Curt mentions a safety zone, dude is across the street.  My young daughters and I were closer than this when REACH landed at a firehouse on open house day.  No shouting was involved.  This is Risk Management in reverse, placing so much fear into providers about cameras that they snap thinking they’re going to get fined for a violation.  Only to make them look a fool the world over.

Let’s take a few IF pills, shall we?

IF, somehow, the video catches some kind of PHI (Protected Health Information) there is no HIPAA violation.  If the crew inadvertantly loses a PCR sheet in the prop wash and the guy on the camera picks it up…maybe, just maybe that could be considered…MAYBE…and incidental disclosure of PHI.

The fine?

Nothing.

So long as the agency can prove they did as much as they could to prevent the paper from flying away, no harm no foul.

There, isn’t that easy?

So why all the fear around the privacy legislation?  Because it’s changing?  Have you read the changes?  Still won’t include dude on the sidewalk, still won’t fine you for letting dude film and still won’t require personal liability insurance in the event of an incidental disclosure no matter what the insurance salesman tells you.

After dozens of pages determining if your agency must comply with the legislation, HIPAA says this: (paraphrasing)

“Don’t be a dick. Don’t tell stories about people or take pictures or use their personal information, OK?”

It does not mention violating the freedom of the press in the name of a law you never read and clearly do not understand.  GRANTED the Angery Captain never mentions HIPAA in his request for code 3 PD (I can hear Motorcop’s eyes rolling), my guess is that was the reason for his outburst.

More importantly…WHAT IS THAT TRANSPORT UNIT?!?!

That thing is a BEAST!  I cringe looking at the front overhang and thinking of some of the hills in San Francisco.  Sure we have Engines, Trucks and Squads with overhangs, but they are much higher centered.  And a crew cab?  I like it for the future of EMS being more centered on getting patients places without having to recline them, but dang, that’s a lot of space.  Can anyone speak to the history of this design in Miama Dade?  I like the idea of something new, but it still looks like a box on a frame.  It appears to be a Spartan RT.

Is the Captain in the video Angry abou these rigs perhaps?

Reader ryan chimed in on a topic more or less already covered to death, the Bakersfield “nurse” that said she couldn’t do CPR on a person who collapsed.

We learned after the initial uproar that the patient had expressed a desire NOT to have CPR performed, but did not do so through the usual channels.

We have also learned that the facility stands by their policy to, well, stand by if you collapse.

ryan commented:

"im still confused on this, isnt there a duty to act the same as an emt who is at work?"

Nope.

Nurses do not have a duty to act under their licensing.  It is true that if the facility hired an EMT to wander the halls they would be required to administer CPR regardless of company policy (and in the absence of a valid DNR of course) but this “nurse” had no such requirement.

I use the term “nurse” carefully here.  I’m not discussing Nurses or Nursing but instead the gray area of “nurse.”

I’ve been on more calls than I can count where someone presents themselves as a “nurse” then makes it painfully obvious they are not any such Nurse I’ve ever heard of.  Then after the patient begins to recover because of our interventions expresses that they are a nursing assistant, student nurse or any variety of care giver, but nowhere close to an RN.

More concerning to me than the lack of a duty to act was the almost complacency by the 911 caller to identify herself as a nurse, then refuse to give care.  In this economy I can understand wanting to keep a sweet gig like that one.  Imagine getting called a nurse and not being allowed to help people.

Multiple sources list her qualifications differently, so much so that determining her level of accreditation, experience and licensing can’t be relied on so I have to go with “little to none.”

It’s frustrating to think this facility sells this product, promising to call 911 instead of intervening or, better yet, educating their clients to seek out proper advanced care directive documents instead of a “we promise not to do CPR on you.”

Imagine if she wandered off site for lunch and this “nurse” was also at lunch off site and the same thing happened.  Now ask yourself if it’s just as absurd.

Thanks for reading ryan.

Now that I have your attention…

EMS 2.0 co-creator and noted ginger Chris Kaiser (CKEMTP) from Life Under the Lights is having a bit of trouble with his toilet.  Well, washroom, well…oh dear Lord, let me just show you the picture.

Damn, Kaiser, that sink alone makes me question our friendship.  And is that duct tape in the shower?  My God man…

Thing is folks, Kaiser has a chance to make things better.  He has been entered in an online contest to win a bathroom remodel that will take the abomination in that photo and turn it into something he can be proud to…well…um…use.

Many of us have been voting for him but he needs your help.  One of the competitors may be trying to buy votes from voting farms (No, I didn’t make that up) in Korea or parts unknown.  Since I’m the closest thing EMS has to a Kim Jong Un I am blegging you to help one of our own before I call in Dennis Rodman.

Follow THIS LINK and vote.  Then come back to HMHQ tomorrow and click the link to vote again.  You can vote once per day.  Yes you have to log in to the site, but only the first time.

CK is a brave man to even post that picture.  Now imagine the shame if he doesn’t win and we all know his bathroom still looks like that.

Sad.

Get voting!

Our local teaching hospital / trauma center / STEMI center / stroke center is putting on a new lecture series which focuses on STEMI and ROSC patients.  It is very similar to the trauma seminar I’ve mentioned before and has a wealth of information.

It starts with our pre-hospital radio report and continues through the balance of care for the patients.

My favorite part was when the MD leading the presentation suggested everyone in the hall go to a blog for ECG knowledge.

Mine?  Of course not, not until the seminar on fart jokes and grammar mistakes.

No, he directed us all to “Tom Boot-hill-aye” and his excellent work at EMS 12 Lead .com.

I will admit I sat a little taller in my chair when someone I know was mentioned as an expert in his field…and uses a blog to disseminate it.

Sure Tom Buothillet speaks nationwide about the importance of pre-hospital 12 lead ECGs, among other things, but also uses social media and video to make his message more powerful.

Tom recently debuted the London Ambulance Service episode of CODE:STEMI where he travels the world talking about EMS systems and their reaction to sudden cardiac chest pain and arrest.

Good work Tom, keep it up!  I think you’ll get a few more hits from today’s session!

This post was a good example of venting.

You write down your thoughts, purging them from your head, then come back in the morning to see if you still feel that way.

The only drawback being that if you forget to change the publishing date, it finds it’s way live.

I should listen to my own advice.

If you saw my opinion on the Bakersfield event, that’s what it is, my opinion.

You read that right.  San Francisco has a cardiac arrest survival rate of 100%.

Does that mean that everyone who suffered a sudden cardiac arrest survived?

Of course not.

But our survival rate is still 100%.

That’s because today my numbers for witnessed Asystole with ROSC and cooling measures look really good.  So, our rate is officially 100%.

Hogwash you say?  How is that any different than some communities who bend their inclusion criteria to give the impression that they have an amazing rate of survival when their overall numbers are a complete unknown.

I rub my temples when editing our CARES registry, not because the data fields seem unending, but because there is one that I’m not sure we should be editing until long after the event:

“Suspected Cardiac.”

This term sits in a line with others such as drowning, respiratory, trauma etc.  Since our cardiac arrest patients seldom tell us what led to their arrest, we have to make a HUGE assumption and hope the hospitals update the information accurately.  That is also assuming that the hospital was able to discover the cause of the arrest.

It would be refreshing to be able to determine the cause of cardiac arrest and only count the patients we were going to be able to help at all, but that should not be taken into account when reporting survivability.

Imagine it this way: Our major trauma survival rate is 99% because we don’t include patients who had a BP of less than 50/P in the field since our efforts are unlikely to impact them.

Insanity, right?  If trauma care and survivability from injuries is our population, why exclude those who are less likely to make it?

Because it makes us look bad.

We can argue the semantics of statistics, reporting and the like for decades, we have and we will, but make sure when someone reports 60% survivability from a condition that kills more than 90% of those who suffer it, ask what they mean by “survival” “cardiac arrest” and “witnessed.”

It’s all in who you place in the denominator that decides your final answer.

So when I neglect to tell you our survivability only includes tourists with witnessed arrest who received bystander CPR and an ALS intervention within 4 minutes, am I really telling you the chance of you surviving cardiac arrest in my community?

Nope, but it sure is fun to say.

What is our actual rate?

We don’t know, some of our 2012 patients are still in the hospital.  Some communities might count them as survivors and move on, but we’re looking for total survivability, not simply a target some time after admission.  It will also help us guide future interventions if we can wait to learn exactly what happened to cause the arrest in the first place.

Sub point being that putting all your efforts into community CPR may seem like a fantastic idea, but if none of your survivors received it, will it make a difference in your community?

None of your survivors received cooling measures…does it still have an impact in your community?

No one who had a transport time of less than 5 minutes survived…should we slow our response?

Asking questions like this comes from looking at the data with too fine a comb.

1/2 of 1% (.5%) of the patients seen by my system are in cardiac arrest.  Of that group upwards of 90% do not survive, many of them being beyond our help before we arrive.  So now look at the subset of the population we’re observing. 10% of .5% means .05%.

That’s 50 cents out of a $100 bill.

Are you willing to change your system, your community, your children’s graduation requirements… for .05% of your patients?

While I’m a big fan of community CPR, I’m also a big fan of community asthma programs, community hypertension screenings and community programs to reduce unnecessary 911 calls.

Those programs impact a far greater population and while there are not immediate results, like in ROSC, we are preventing far more cardiac arrests 30-50 years from now.

Which is better: Preventing an arrest, or classifying one so as to show success?

Hard to prove a negative.

EDIT – I was contacted by someone I respect very highly who informed me my stance has been misinterpreted (ie I didn’t get my thoughts out the way I thought I had.  Not the first time either, go figure).  I am not calling for the muddying of the waters when it comes to Cardiac Arrest Survival rates, simply that agencies know what they are reporting and, more importantly, WHY!  I’m aware I come off as a non-believer in this post, implying that all the new fangled stuff doesn’t work, I just want to make absolutely sure we don’t all focus on one outcome at the possible expense of others.  My views may be confrontative, ill-advised and downright wrong, I’ve never claimed to have the answers, but in my current position of gathering and interpreting data I see how easy it is to steer the results in my favor.  It’s tempting when someone survives cardiac arrest and goes home mere days later…yet doesn’t fit the Utstein numbers, so doesn’t “count.”  It’s also frustrating when we have an Utstein case arrest in the ambulance and not survive.  The one person we think we have the best shot with and there’s little we can do or learn from it.  Agencies like Medic One and Hilton Head Island, with impressive Ustein results should be admired. They’re using their data, learning from it and applying it.  Good for their patients (and good for them) but if you are not part of the CAREs registry make damn sure you know your metrics and are reporting apples to apples, otherwise you’re not only fooling yourselves, but doing your patients a disservice.

-HM