The curious case of the blue pill

Preface: This isn't a clinical post as per my usual social media banter. Feel free to skip and carry on. But if it still sounds interesting, buckle up.

I finished my EMS shift yesterday after a long and busy day meeting a lot of patients whom by far were not in any need of any critical lifesaving interventions. And in typical fashion I went home, poured some wine, turned on the Spotify, and in perfect timing I came across Rick's Rant (No, not Rick Mercer walking down a Canadian alleyway, but Dr. Rick Pescatore's rant on Twitter) and it struck a chord. I will share his rant below because I think it needs to be shared and read by anybody involved in prehospital or in-hospital emergency care. And I can't say this describes EMS to a nutshell but there are some certain parallels in his diatribe to our industry as well.

Not every EMS call will involve cardioversion, a lifesaving medication, or chest compressions. The reality is that quite often, and the predominant majority of paramedic call volume will be simply treating some symptoms of a larger chronic disease process. Or even just a low key ride to the hospital. And that's just the nature of the business we are in today. While old school stalwarts and some newer ones will argue that an ambulance should never be used for anything less than life threatening conditions - and I get that argument - the reality is we are in different times and I don't think that we will ever get back to those days of old where most 9-1-1 callers were very sick. And I get that complex clinical cases are important to the Paramedic skillset. We need those high acuity and unknown calls where our brains and motor skills are put to the test so that we remain sharp providers. But rest assured those events will always exist, as we push the envelope of aging and medicate patients to the maximum possible life span. And as our population grows, and grows older and patients continue to ignore the advice of their physicians and ignore their medication blister packs... those calls will be there for us too. And yes if these were the only calls we ever attended one could argue our skills would be razor sharp and the agency I work for may not need 26+ Paramedic crews on day shift and we would feel much less overworked and drained after a 12-hour shift. And don't get me wrong, I'm not an apologist for the lack of resources that has plagued our industry since ambulances existed. We could all use a little more help and a few more trucks on the road. But that isn't the time that we are in anymore. The causes of todays EMS call volume are complex and include changing attitudes towards what patients consider an emergency, lack of access to general practice care, and lack of available 24/7 care options outside of the emergency department. But we can't control outside factors so we must be adapt and overcome.

So the reality we are faced with is that many calls today will involve some basic care, maybe some medications to treat symptoms, and a helping hand. But that doesn't mean any patient should be treated any less or we try to determine whether or not this patient is "deserving" of our training, education, and skillset. Open up any type of social media, especially Facebook and go to any EMS related page. The predominant theme you'll find on it nowadays is that its cool to be "burnt out" or "salty", and that this determines ones worth. Mark my words this will be industries downfall. Yes, Paramedics face a myriad of stressors on a day to day basis, and escalating call volumes don't help the situation. And once in a while it's ok to have a bad day, it's ok to vent (and I appreciate the fact that there are many inside and outside factors for burnout in EMS that have nothing to do with this topic). But for gods sake don't treat your patients like shit and wear it like a fucking merit badge. The only thing that creates is a public who will never support us, and never trust us. And we absolutely need their trust as we change EMS service delivery to one that needs patient faith and trust when we say "We are going to treat you here at home" or "We aren't going to take you to an emergency department, we are going to take you to an alternative destination to best meet your needs" (be it a detox centre, urgent care, mental health facility, etc).

It starts in future generations of Paramedic students. They need to be trained, educated, and supervised by those that acknowledge this new reality. Not raised by those feel that each patient needs to meet some set clinical bar to be worthy of our service, or that the only way to be respected and accepted is that you need to be "salty". Students are easily molded and quite often follow in the exact footsteps of their preceptors. There is no role for judgement in our job. There is no place for burned out care in the upbringing of future Paramedics. The rest of us need to stand against this nonsense and fight against the stereotype that broken is the way to be. There is no place in our industry for these types of providers.

The tides in EMS are changing and we need to accept this. We are conducting prehospital research and applying what we learn from that research in a timely fashion. We are doing amazing things in this shift like community paramedicine which reduce 9-1-1 call volume and keep high frequency users at home. We are putting together specialized treatment teams for lower acuity calls such as addiction and mental health and keeping these patients out of emergency departments where EM physicians struggle with these specialized care niches. We are delivering care to the right patients at the right place at the right time. And the only way to be successful is to acknowledge the fact that a large part of this doesn't involve critical interventions but tailored treatment and paramedics free of judgement who provide top notch care and customer service on every single call regardless of acuity. Because one day "You call, we haul" will be a thing of the past. And to get there we need patients who understand that when they call 9-1-1 for (whatever problem) and we offer many more solutions than 1) We are sending you an ambulance and 2) taking you to an emergency department, that they have the faith and trust in Paramedics that the solution we provide is the right one.

So where do we go from here? Two choices are in front of us. We can take the blue pill and go back to doing the same old - being salty, teaching salty, and hating the fact that the majority of our patient encounters called 9-1-1 "for this?". Or we can take the red pill and acknowledge there is so much more to what lies ahead for the future of Paramedicine and be proud of it. "There's a difference between knowing the path and walking the path" ~ Morpheus.

In closing I leave you with the original rant as authored by Dr. Rick Pescatore. You hit a home run Rick, thanks.

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@Rick_Pescatore: Emergency medicine is dying, and it's the ultimate irony that ER docs will sit idly by as the specialty circles the drain, bradys down, and dies a terrible and dirty death by its own hand.

Fifty years ago the speciality was born. A handful of great men and women--titans--recognized the need for highly-trained, endlessly innovative, and fearless physicians to stand ready for anything that might breach the ER doors---24|7|365.

Over the past five decades, EM has defined itself as much by tending to the critically ill and injured as by serving as the enduring safety net for the marginalized and disadvantaged.

The ER has become the last shining light on the hill for Lady Liberty's huddled masses. We've been the golden door. We've held the lamp for the tempest-tost, the tired, the poor.

What's more, driven by the power of global connectivity+the cornucopia of #meded information sharing, Emergency Medicine trail-blazed in medical education, asynchronous learning, and continuing education. Somehow, lightning struck twice. Another generation of titans came along.

But the tides have shifted. Through corporate influence, the unrelenting medicolegal spectre, and an image problem that would daunt even the most accomplished PR firm, Emergency Medicine has forgotten the culture of compassion and ingenuity that brought us to where we are today

Rather than asking "how can we help," loud voices insist on changing the narrative to "so what," implying that some bar must be met to merit our services+expertise. We focus on+champion rare/invasive actions, when all along the simplest tasks make the greatest difference

But the bar was long ago set as a stepping stool, not a barrier. To continue to restrict our knowledge bases and interventions to life and limb threats is to ignore the greater half of our mandate--to stand ready for the wretched refuse, the tired, the poor.

And the patients suffer.

And the consultants suffer.

And the learners suffer.

And we all suffer.

...all because of a generation of entitlement, elitism, and abdication of responsibility.

Emergency medicine is dying, and needs resuscitation. It needs a refocus away from corporate ephemera, whether or not I can have snacks at my desk, and how much Yoga it'll take for me to not blow my head off after yet another shift where the speciality is denigrated or i witness shit medical knowledge passed down to liability share, shift responsibility, abdicate accountability, or perpetuate a bastardized notion of what the emergency department means to our country's most in-need.

Emergency medicine is dying, and it's an enduring tragedy that we band of resuscitationists, we merry band of doctors so enamored with our ability to stare death in the face and live to tell the tale, will stand by and watch until the monitor sounds its final tone.