Definitively the Ultimate Pre-hospital Advancement (DUPA)

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For years US EMS has struggled to come to terms with the realization that EMS outside of the US, rather than a bunch of vocational laborers paid to drive people around in trucks for minimal pay, are educated and professional providers of out of hospital care which has a measurable impact on the lives and health of their patients.

In many nations this takes on the form of a degree, by which policy makers and the general public gauge the economic and social value of its members.

In contrast US EMS providers and their various bodies, such as their testing organization, NREMT, their (permit me to be generous) “professional” organization NAEMT, and even educational curriculum designers, and numerous other organizations have not only resisted requiring university level education, but actively take steps to make sure attaining professional status is inhibited all the while making money making providers feel like they have obtained some level of demonstrable knowledge. They even celebrate this abbreviated education and knowledge by handing out cards demonstrating capability.

We all know the cards, BLS, ACLS, PALS, ITLS, PHTLS, NRP, AMLS, BBLS, ABLS, BDLS, and on and on.

The government not wanting to mandate education concurrent with the responsibilities of EMS providers as well as the sensibilities of other first responders such as fire fighters even develops their own “training” in the form of NIMS, et. al., also choosing “add on” certification classes composing of mere weeks or even hours of “education.”

Most of this “education” is at a level so basic it is almost intuitive. At the very least it could be done in far fewer hours than is being allocated and advertised. But it all has 1 thing in common. It does not confer a degree. You know, those things that come with a couple of letters that society values. That policy makers respect. That little piece of paper that forces employers to pay more when everyone is required to have it. It comes with letters like MD, DO, RN, BSN, RRT, PA, BS, BA, MA, MS, PhD, DsC. etc.

The hours of many if not all of these classes are not even transferable towards this elusive piece of paper. It reminds me of the scene in the Wizard of Oz, where the wizard is giving out his promised payment for the broomstick of the wicked witch. When he is tasked with giving the scarecrow his brains, he announces, that the scarecrow has no fewer brains than other great thinkers, but lacks a diploma. If you are involved with US EMS, that scene pretty much describes the root of all of your struggles.

But you can go to any social networking site, online publication, print publication, etc. and listen to providers get insulted over being called “ambulance drivers.” You can see them preach about how they are “professionals”, “educated”, “responsible”, and all manner of adjectives and accolades demonstrating their value and importance. As my 5 year old would say “blah, blah, blah…”

The aforementioned courses are not only accepted by providers, they are celebrated. Most of them require you to fork over some money to “stay current”, despite most of them adding nothing new, or so little, that practice is often changed before their guidelines are.

They must be great for people who have ADHD, a few days of utterly disconcerted information that gets you a little gold sticker, er…I mean card, certification, whatever. But I wonder, is the knowledge and or skill really perishable? If it is and requires recert so often, it must mean those certified are not using the information. Logically, if you constantly perform a skill, it should not deteriorate. In fact, it should get better!

Proponents of such “education” are quick to point out that this information, no matter how basic and required for even basic job performance, are effectively disseminated. That’s nice; I could send it out in an email and reach more people more effectively. These proponents are effectively “tricking” people into believing they received some form of useful or even valuable education.

A great example is AMLS. “Advanced Medical Life Support.” As a Physician I was never required to take such a class. However, it took years of both classroom study and practical education in order to provide medical care and life support. But after a quick 2 day course, I could have gotten a basic outline, show everyone my card, and advertise myself as an “advanced medical life support” provider. Of course any knowledgeable professional like a Doctor would instantly dismiss my credential as at best ignorant and at worst with malice. After all, what could you possibly learn in 2 days with no base of knowledge it is expanding on?

Some claim these classes are often “the best education” or classes they have ever had. Compared to what? Similar courses? Initial training? Sitting around with your coworkers and friends drinking beer and talking shop?

But as the old saying goes “if you can’t beat’em, join ‘em.” So I will be developing a class. It will be “taught” over 2 days. In a bar, casino, or strip club. We will drink and engage in a group discussion (we’ll call it collaborative adult education in order make it sound legitimate) about studies, basic science such as anatomy, our experiences, and opinions. We’ll ask a few philosophical questions, eat, joke around, and go back to our respective hotels for “private” study time. At the end of the 2 days, we will officially hand out DUPA cards. This card will be good for 2 years and unlike course completion cards, will officially certify you as meeting all the requirements of being a complete DUPA. I assure you, it will be one of the best classes you ever take, but unfortunately it will not confer a degree just like all the other ones and you will probably look forward to doing it again after your card expires in order to stay current in your knowledge. Instructor courses will also be available for an extra fee. Make sure to put that at the top of your resume, LinkedIn, etc.. In fact, use it as pre or post nominals. Show off your new knowledge and skill by making sure it is on your name badge in giant letters.

For those who do not speak Polish, under no circumstance are you to put this title in google translate.

The evolution of the emergency department

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Anyone who knows me has heard me say many times that primary care as both a medical specialty and the way it is delivered is a failure. More than a few souls have also heard me say that the emergency department is the modern version of primary care.

So why am I writing it here again? Because there are still people out there who haven’t got the message yet…

Every day from providers being angry they are for real emergencies in the US, to billboards in the UK, and every blog that comes across my screen from EMS, to medicine, to nursing, seems to have an abundance of supposedly scientific people who do not believe in evolution.

Not the Charles Darwin theory of evolution, though that certainly applies, because anyone who thinks they exist to only take care of life and death emergencies would not only ideologically, but also economically put themselves out of existence. Let’s have a closer look shall we?

The emergency room, or emergency department today was developed in a time when medical science was not very advanced. Rooted in symptomatology medicine as a profession really didn’t have much clue on how the body worked until the explosion of the sciences of biochemistry and molecular biology. (Roughly 30 years ago now.) Unfortunately, many providers and even clinical guidelines, still attempt to use symptomatology for the diagnosis and treatment of diseases. I see it most often in what I call “cop out” diagnosis; a diagnosis of a clinical symptom as an actual disease process rather than a symptom of an underlying pathophysiological process.

Cancer is a pathophysiological process. Symptoms include tumors, weight loss (from catabolic metabolism), etc. Cancer is a diagnosis. Cellulitis is a symptom. There are many things that cause the same symptoms, but successful cure requires identification of the underlying pathology; vascular insufficiency, from various causes like diabetes, fungal infection, bacterial infection, etc. Cellulitis is a cop out diagnosis. Treating like a symptom is only good if you are using your patient to make your car payment. You give a treatment that temporarily resolves it, do no further investigation, and sometime later it returns, forcing your patient to also return and pay you again for the job you should have done prior. Atopic dermatitis is perhaps the most abused of the cop out diagnosis.

Let me explain how this applies to the evolution of the Emergency department? Sudden cardiac arrest (the epitome of cop out diagnosis), stroke, myocardial infarction, ruptured aneurysms, severe trauma, etc. are common life threatening emergencies. They are not the only life threatening emergencies, but generally regarded as something worthy of a visit to the emergency department. Providers, specialists or otherwise, do not really treat these diseases. They call the people who do; surgeons, cardiologists, neurologists, and the like. The reason for this is simple, advancement in medical knowledge has led to the understanding these are not random, unfortunate, things that cause people to get sick and die. There are even predictors to major trauma.

You often hear providers talk about “stabilizing” before definitive treatment, but this is not something that cannot be done by other experts. Providers in emergency departments as well as other medical environments, whether they are emergency specialists or not, have the knowledge and ability to institute life-saving treatments specific to their practice.

When I hear emergency doctors and nurses complain they exist for true emergencies, it is fairly clear they do not. After all, you won’t find PCI going on in the ED. They are not fixing aneurysms down there. Stroke teams consist primarily of neuro-specialists, neurologists and surgeons, the ED is not doing direct arterial TPA, or craniotomies. Delivering a baby in the ED means unfortunately the patient could not be taken to OB fast enough. Even if you consider the volume of “true emergencies” it is so small, that it can be conservatively estimated to account for less than 10% of all ED visits. Most of the statistics I hear are less than 5%. In every medical system I know of, money is driven by patient census. The fewer patients you see, the less money you get. That doesn’t change in single payer or private payer systems.

How would your organization look if your census was only 5% of what it is today? Would you have as much equipment? As much staff? How many emergency departments would even exist in your city? In your region? In your country? I strongly suspect far fewer than do now. Would you even have a job? Would you even be employable as “an emergency expert?”

This leads to one conclusion. Life or death type emergencies are not why the emergency department exists. So what do they exist for? Well, if you look at what emergency departments actually do, it is clear they provide effective primary care. They have a fair range of diagnostic equipment on site which permits relatively accurate diagnosis, which results in the patient treated and released, with or without follow-up, or a referral/transfer to the appropriate specialist. EDs are also open 24/7. Let’s face it, the fine upstanding members of society will probably only require an ED a handful of times in their life; perhaps only once.

Statistically, MI’s occur before primary care opens. Trauma happens after it closes. People cannot miss extended periods of work to see a doctor. As the knowledge of the human race increases, individuals become less diverse. As an example, even healthcare providers are not able to keep up with things like vaccination science. But chances are, the average economist doesn’t know much about medicine. Many may not even know simple things like how to treat a fever, when, and why. (why being mostly for comfort) Imagine how little the less educated know. In the modern world, people need and demand answers to their questions almost instantaneously. Am I sick? Do I need an x-ray? Do I need a medication? Is it serious or not? What should I do to help my kid? Are they serious? Am I a bad parent for ignoring and not investigating or seeking help for their potential medical problems? Did I hit the gym too hard? Did I drink too much? Did I overdose on my recreational drugs? Why does it burn when I urinate?

The alcoholic does not need a 9am appointment with the primary care provider. He probably can’t even make it to an appointment before 1pm.

What’s more, in medicine experience counts. How do you know if somebody is serious or not? From seeing lots of non-serious patients…Even in respective education you learn what is normal before abnormal. You learn what is easy before what is complex. What many are dismissing as “bullshit” is actually the basis of their expertise!

Primary care on the other hand is not 24/7. Most providers have only basic, if any, diagnostics. They cannot answer the questions people go to the ED for. Not only that, but routine cases have prescribed, scientific based guidelines. The cases are so simple they do not even require a doctor. That is why many nations are adopting the Nurse practitioner and Physician assistant. They cost less to produce and pay and can follow guidelines as well as anyone.

In Western society, the major illnesses are now acute exacerbations of chronic disease or acute on chronic disease. A myocardial infarction, sudden cardiac arrest, pneumonia in CHF, decompensation of COPD are not magic, unpredictable acute conditions. About the only ones that exist that way are infection, trauma, and poisoning to some degree.

EMS providers often mimic the attitude of “emergency” professionals. Their whole training and purpose is based on that 5-10% of “real emergencies” as they existed in the 1960s and 1970s. But the economics and value to society is the exact same as those in the emergency departments.

Knowledge has changed. Society has changed. What is considered an emergency has evolved. Why is there resistance to evolving with it? Why do people not realize or accept this evolution? I find it hard to believe emergency providers are that ignorant. So if it is not ignorance it must be stupidity; knowing and intentionally not accepting. What value does somebody who can only address the concerns of 5-10% of their patients, customers, John’s, whatever, provide? Who could stay in business doing that? Why would anyone allocate massive resources to it? Bottom line, nobody should. It is not worth it.
When you publish your blog post, Facebook post, editorial, public service campaign, billboard, etc. talking about “abuse of the system”, the real reason emergency exists, etc. you demonstrate just how fucking stupid you really are. You have no idea what your purpose or value is. What your knowledge and experience is. You do not see the forest from the trees; because if you do, you are purposefully acting in contra to it. either way, you are hopelessly out of date, and you no longer have any value. Do the rest of us a favor and retire or find some other line of work. Tell your boss you are only doing 5-10% of your job. Let me know how that works out for you. How do you think it would work out for somebody in an industry other than healthcare? How would it look if McDonalds put up a sign and advertising campaign they only wanted to serve 5-10% of the population?

The problem with emergency is not the “patients” misusing it; it is the providers not wanting to do their job. The reason it is such is because of the ineffectiveness of primary care, not because people do not want to use it or don’t know about it. But it doesn’t change reality on the ground. The ball of primary care has been passed to “emergency.” The only choices now are to quit, fumble, or try to score. Said another way, you can quit your job, you can be incompetent at your job, or you can try to be great at it. It is never going to be your fantasy of only life and death, “real” emergencies.

An outsider’s view of the Polish medical crisis.

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In my first ever blog post, I wrote about the difference in mindset and approach to patient care between critical care providers and medical providers of less acute disciplines.

This past week in Poland I have been the antagonist of several doctors who are upset over the mandated changes in Primary Care by agreeing with the dictates of the Ministry. I stand by that position.

Despite the dictate being deftly packaged as earlier detection of cancer, what it really is demanding is a change in the way which Polish primary care providers practice. While they may not want to change practice for a variety of reasons, like an ultraconservative culture, a completely unnatural level of focus on wealth and material possessions, or just people set in their ways who don’t want to do something new in order to justify to themselves what they have been doing all along.

Polish primary care is broken. It is broken beyond repair. In my observation and experience it is not worth paying for in its current form. Not by individuals and not by the national health system.

But it is not alone. I do not know of even 1 country in the world that has an effective functioning primary care system. Unlike the US, which limits access to primary care, primary care access in Poland is in abundance. You don’t even need an appointment. Walk right in, first come first served. There is not even triage to give priority to the patients who might be on death’s door. Pay nothing out of pocket. If you like you can go to a doctor and pay out of pocket for private non-national health service. Most doctors I know work in both. I even know a few that do not work for the national service (NFZ) at all, preferring private practice and its increased income.

I actually see that as a strength of the Polish system. Everyone is guaranteed a basic level, but if you can buy more, you can have more. How is it even possible to find fault in that? Nobody goes without and nobody stops you from spending extra to get more. Maybe it’s just the American culture in me who appreciates that?

That is the theory anyway, but…being a tried and true, in the trenches, operations guy let’s look at how it plays out in the real world? I have actually had to go see a doctor a few times during my stay in Poland. My family has had to as well. I also spent many hellish hours over my internship in a PCP office endlessly writing prescriptions and counting the minutes until I could escape each day. As I already attested, I have had not one, not 2, but now 3 people show up at my door to ask me my opinion on what their doctor’s advice was. I suspect this will continue.

You go to the Polish GP, if you don’t die waiting in line for an hour or two, and I have not seen even 1 who has, you get to go in to see the doctor. When you enter the office, there is usually a desk, a chair, a sink, and an exam table that barely functions, when it is not outright broke anyway. It is no frills. In fact, you could replace it with an actual table and it would cost more for the table than these things do. You of course get what you pay for. The equipment to be found in the office usually consists only of the stethoscope and blood pressure cuff the doctor brought with them and a box full of tongue depressors. When I take my daughter to see her official pediatrician, I actually have to bring my own otoscope for the doctor to use. The same applied when I took her to both an urgent care and the ED once in the same night. The only place I have actually seen an exam light is in an ENT clinic. It too is an old school head mounted device with a mirror. In one PCP clinic they actually had a 12 lead EKG machine. The long and short of it is, they have no equipment to speak of. Certainly not enough to do any sort of quality level exam. If you need blood tests, x-rays, or the like, you get a referral. As before these centers which are often not even in the same area of the city, are first come, first serve. They also limit their hours. So for example, they will say “We draw blood from 7am until 9am.” So if you miss the window you wait until tomorrow. You then wait a day or two pick up your results, and go back to the doctor who referred you. Total time lost: 3 whole days.

But most often, the primary care doctor doesn’t even believe they need diagnostic tests or labs. They do a cursory and often pointless physical exam which consists of: depressing your tongue as you tilt your head towards the overhead lights meant for the room. (Never once could I ever see anything but a big black hole doing this with my 5:1 acute vision, but they pretend like they can) Then they listen to your lungs and bronchial sounds with their Littmann stethoscope. (After all, have to demonstrate the ability to afford one) Some will listen to your heart sounds, some will not. Then they will palpate your abdomen. All of this is totally independent of presentation or complaint. So If you come in with a chief complaint of not being able to shit, they will “look into your throat.” (and still only see a big black hole) I was present once for a patient concerned he had herpes, forget a swab, the doctor didn’t even look at his penis. She just said “I don’t think you have herpes” and prescribed him a topical antifungal. But she is not alone. This is how they all operate. At least everyone I have encountered in the past 8 years. Sexual history is not even part of the exam for STD patients! I am told because in Poland that topic is taboo.

These doctors do not believe as I do, that if you must provide your own equipment to do an acceptable job, that is a necessary out of pocket expense. Consequently, my home has more and better medical equipment than most PCPs. As a personal value, I believe to do a quality job, you need quality equipment. I am also at the point in my career where I can appreciate quality equipment. There is also something about professionalism demanding that your tools be a reflection on pride in your work. 1st that you actually have them. 2nd that they be in good working order. 3rd that they be presentable. It is clear Polish primary care providers working with NFZ and even the private ones I have seen do not share my beliefs nor have any professional pride. Yet those same ones like to buy the finest quality automobiles, homes, and other such things, they cannot spare even 1% of their salary to effectively do their jobs.

My conclusion: They have no pride in their profession, but they are greedy. They also demand their status at the various level of doctor and experience be held in highest esteem and respect.

Not only do I take issue with it, the patients do. They actually write op eds in the local newspapers about the poor care they receive regularly. There are websites devoted to rating doctors. They even research what the standards of care are in other nations. They research what diagnostic tests should be ordered. They research the treatment options. They even examine themselves before they come. Polish doctors know about this, they talk about it. Rather they complain about it. “Who do these patients think they are? I am the doctor!” Well… It’s my opinion they are looking out for themselves and doing what the doctors should be doing. But Polish doctors not only ignore these patient expectations, they purposefully act out against them.

The doctors diagnosis is often based solely on epidemiology. Exam findings if even available, overlooked. I can assure you not one will ever diagnose you with upper respiratory bacterial infection requiring antibiotics, In fact the last time I went to one, I already knew I had a peritonislar abscess. I knew because I examined myself, drained it myself, and wanted a referral to ENT so I didn’t have to pay a private one. I was told, “I think it is a virus.” You can imagine the surprise on the doctor’s face when I told her I was also a doctor, my findings, and treatment. There is now a big note at the top of my chart warning subsequent doctors I am also. That is one example, but it happens all the time. I have witnessed it countless time from the other side of the desk. If a patient is not a physician, it is even worse. They get their diagnosis of “viral infection” a prescription for a bunch of highly priced over the counter and herbal remedies. (naturopathy is really taking hold here) and then sent on their way. A few days later the patient comes back, finally gets some diagnostics ordered, 3 days later usually gets the absolute most basic prescription treatment, and referred to a specialist. Time lost: minimum 5-7 days.

Not surprisingly, with no diagnostics and no meaningful physical exam, patients are misdiagnosed all the time. The doctors are essentially trying to guess the diagnosis. Because it is epidemiologically based and reinforced with the bias of experience without any evidence at all, diseases like cancer are rarely diagnosed, much less diagnosed in time to actually help.

When the PCP sees something they cannot treat in the office or forces them to do things like prescribe potent antibiotics, like a patient with scalded skin syndrome, they refer them to specialists, often the wrong specialist because of their utter lack of familiarity with all but the most common diseases. So this such patient, who could easily have been treated out patient, was sent for a vascular surgical consult to rule out bilateral DVT. The doctor did not recognize the disease and their best guess demonstrated they didn’t even know much about the disease they were writing a referral for! Again this is one story, but I have many drinks worth.

So, the long and short, the ministry has stepped in where doctors have failed to oversee themselves. A directive was issued, and all the doctors are complaining, signing petitions, and striking. They are not too impressed with my opinion either.

Now they will be required to actually perform some diagnostics. They will have to buy the machines which are often relatively inexpensive to buy and operate, and compact enough to fit on a table. They will not be paid more for it. But being as they are essentially paid for nothing as it is, it will cut into the car payment fund. Maybe they will have to buy a VW instead of a Mercedes. Tragic I know. But what really bothers them seems to be they do not feel like they should have to change. They want to continue to be paid for poor guessing and even poor medical care. Their delusional belief is they are acceptable just how they are and they should be permitted to keep doing what they are doing. That they should be paid more for doing something they should have been doing all along.

They also wrongly believe that what I have described here are a few “bad” doctors and not systemic problems. Some have even tried to deflect their failures on the systems design. The system design is not bad, the problem is the doctors are basically gaming the system to get paid for doing as little as possible or nothing at all.

They are lucky I am not the minister, because there would be some serious quality control put into place. Mandatory equipment, regularly inspected. Mandatory chart review. No payment for complications of misdiagnosis. No payment when the only service is referral to a specialist. Reduction of payments when patients are excessively referred to specialists for easily treatable conditions.

The goal of Primary care would once again be to treat as much as possible without having to refer to a specialist. If that meant doctors had to spend more time with continuing education, so be it. If that time was uncompensated, that dedication is part of professional pride. If it cuts into the earning power of doctors who are already top earners in society. Well…Too fucking bad. If they don’t like it, they can go work in another country that pays more. But they won’t. Not because they don’t speak the language. Because they will not be paid in those systems for doing the nothing they are getting paid for doing now. They would also likely face far more deserving lawsuits as well as professional censure.

But the best part of the whole thing is they are claiming changing what they are currently doing would be bad for patients. How could it possibly be any fucking worse?

“tacti-Kewl” and whackers. What has being at war for 13 years done?

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My last 2 posts were about the loss of perceived neutrality by society of EMS providers and by extension public safety officials and medical providers. Over the holidays this has been a hot topic of discussion within the circles I regularly associate with. My friend of DT4EMS fame, Kip, recently filmed a short video (I am not sure if it is publically released yet so no link here, check out his website. DT4EMS.com) about “tacti-cal” vs. “tacti-Kewl” (phrases entirely of his making). In this video he basically puts my thoughts into much easier to digest form. But during the discussion, I started to wonder how, where, and when this all started. In the last post, and for many years prior I have lamented the change in the attitudes of public service and emergency providers in general post Sept. 11, 2001. But Kip’s video, coupled with a recent news article about the Afghanistan war, and the ongoing coverage of Putin’s Russia, has led to my “Eureka moment.”

Since September of 2001, the United States and many allied countries have been on war footing. In addition to the near constant attacks on Israel, as well as the whole Kamikaze attacks on the US, civil wars in Africa, and several instances around Europe and South East Asia, Islamic extremists have basically been attacking Western values at every turn. Let’s just dispose of the political correctness and call a spade a spade. I don’t see Catholic suicide bombers flying jets into buildings. I don’t see Jewish people selling women into sexual slavery, I don’t see Zen Taoists creating hate groups about women not playing the traditional role of subservience in society, and I don’t see Buddhists demanding the equivalent of Sharia law wherever they turn up from London to Sydney. Now I am not saying these other religions or even some cultures or countries are not without sin, I mean the US tortures prisoners with the support of the majority party in government… Let’s face it, that is medieval in belief and no different than what Islamists are doing, but it definitely contributes to an “Us vs. Them” situation. Basically the conflict of man vs. man, revolving on a set of moral/sociological principles.

All of this has created both fear and need for mental security. I don’t know any person in this world that doesn’t know somebody who has been affected by war in some way. Perhaps they were a soldier or sailor in a war. Perhaps they had a friend or relative injured or killed in war. Perhaps like me, they spent time as a contractor in a war zone. Maybe they are educators trying to reintegrate former men and women at arms into civilian jobs. As broadcast on the news yesterday, for 13 years, more than 3x as long as WWI and WWII, 4x longer than the War in Korea, 2x longer than Vietnam, and infinitely longer than the First Iraq war. This need for security, both physical and mental in daily living has polarized to the extreme all manner of social entities. Of greatest concern to me personally are medical providers and other forms of public safety forces.

When the Iraq war broke out, I was contacted by a student group from a university. The caller explained to me that her student group was looking for a speaker to add an opposing view to their anti-war rally. I asked what this had to do with me, she said she already had contacted both military recruiters and followed up with US military PR contacts, all who refused to speak. My question of course was “So why did you call me?” The explanation I received was that they had learned that many medical advances have come from war, so contacting a medical provider might provide what they were looking for. In the end, we agreed I would deliver a presentation of medical advances from war which was neither pro nor anti- war, and the listeners could make their own conclusions on the cost/benefit analysis. (Who in their right mind becomes the pro-war speaker at an anti-war rally right?) Looking back, these people were protesting what I would say was the beginning of a shift in civilian culture, one that does not seek war or conflict, to one that not only demands it, but doesn’t remember any other way.

When I accepted a contracting job in Afghanistan, primarily at Kandahar Air Field, with a little bit of Camp Leatherneck thrown in for variety, (actually corporate need, but let’s not quibble over terms)many people had basically said their “good-byes” to me like my death was already a forgone conclusion. I didn’t think of it myself as really going to war. More like yet another dangerous environment where people needed medical help, a rather normal event for me. I asked my prospective employer if there would be anyone directly shooting guns at me. I asked if anyone would be lobbing mortar rounds at me, and both occurrences were denied. I did not cross my mind to ask about artillery, so you can imagine my surprise when I first got off the plane and was given instructions on what to do in the event of a rocket attack. My boss and I had a brief discussion about this “oversight” and after the evening rocket attack, I decided it wasn’t intolerable. Eventually it became more of a nuisance rather than a threat, though towards the end of my time, the frequency and duration was making it actually dangerous. Before I went, I decided I should do some research before I got there. After all, you should have an idea what is going on if you expect to help. I looked up various sources on what happened to the Russians in their Afghan war. I studied various publications the military put out, but one that really seemed to be accurate was the psychiatric manual. In it there was a passage about how artillery had the greatest psychological impact on soldiers compared to any other aspect of war. The reason it gave is because every aspect of being bombarded is completely out of the control of the “victim,” defender, I am not sure the right word to use. There are even accounts of soldiers committing suicide from the mental stress of being shelled. But when you look at the modern world, especially in the US and Western nations, there is an overall feeling of powerlessness among the populations. Like the victims of being shelled, the stress over that which affects them beyond their control, contributes to things like PTSD, but it also creates efforts to control things.

I mention all of this because I think it is important background. You see, public safety and emergency medicine gets a lot from the military. It imitates the military often without any thought of whether it is the right thing to do outside of a war zone. Some of it fits, some of it definitely doesn’t. But it often takes a long time for anyone to realize and change what doesn’t work. The other thing to consider is that emergency medicine, related disciplines like trauma surgery, and public safety attract the same personalities as military persons. It provides a similar environment and perhaps the thing most important to me, a certain comraderie. These civilian positions also attract and give preferential hiring to military people. So it is not amazing to discover that the people involved with these jobs after more than a decade, a whole generation, are becoming more militarized.

These seemingly unconnected ideas, threats and actual violence against civilian populations, differences in culture and beliefs, the mental stress of factors beyond control, an entire generation who has experienced constant war, the mentality of providers, and the mental security and behaviors of the military, are all playing a dominant role in the values and culture of medicine and public safety.

Some are beneficial, like damage control surgery, tourniquet usage, defined chains of command during disasters and such. Some are harmful, such as the creation of a caste system, the moral aversion to diversity in people and their lot in life, and the treating of non-military matters as if they were a military mission or somehow using military tactics will solve any problem created. Unfortunately, the later is simply not realistic.

This plays out in emergency circles in many ways, such as the focus on acquiring “tactical” training and equipment to acting like moral police enforcing the values of the providers in the name of safety and protection. Dressing up and pretending to be a military special forces operator has become “cool”. It is said that imitation is the best form of flattery, but consider that if some random person dresses up all military, they run afoul of “stolen valor” laws, but if a police officer or even a “tactical” doctor do it, well, that is entirely a different matter; especially in the name of personal or public safety.

Back in earlier times when providers did things like dress up with all kinds of equipment far in excess of what was needed, “just in case”, did things like put light bars on their personal vehicles, invested in communication equipment that would make the SETI project seem pitiful, and drove around town with all kinds of medical gear in the event they were called upon to “save a life,” we had a derogatory names for these people. We called them Rickey rescue, or whackers. There was no mistaking it was not a behavior that was acceptable, and I suspect there may even be some mental issues with such people. Today though it has been renamed “tactical” and it is cool. Tacti-Kewl.

After all, how can dressing up like an urban special forces operator, showing up at medical event with prefabricated tourniquets, some OD green chemical bandages, and tactical black SAM splints, not be the epitome of a top quality medical operator?

There is no shortage of crazy training for it either. I was employed at one agency with it’s own tactical training. How to intubate and use a bag valve mask dressed in full tactical gear in all manner of insane positions, from under furniture to upside-down in the dark. I often wonder though, What does the combat gear or OD green colored bandages really do in any world, much less the civilian world? It is not like during an active school shooter event anyone will be providing care while obfuscating them from vision. It is not like the drunk guy stabbed in the bar will benefit from not having his bandage seen in the parking lot. Even providers themselves go to great lengths to appear more military. Nothing says “bad ass” like all black battle dress, body armor, a balaclava, a bunch of black or OD green medical gear hanging off of you, and bright reflective lettering that says “police”, “EMS”, or “fire department.” Because when you are dancing around in your all black ninja suit so nobody can see you, it is important not to be misidentified by other ninjas and thought to be a bad guy. Of course you could just have some bright white or other high visibility color with a big red cross on it too…Not very ninja-like I know…

This brings us to root problems; the idea of prevention vs. reaction, and public safety vs. medicine. Let me just get the easy part out of the way first? If you are a medical or nursing provider, working in an ED, on an ambulance, or wherever, you are not a public safety provider. You are a healthcare provider. If you actually learn something from military medics, they will tell you direct patient care cannot be provided for under fire. You will not be providing care under fire, you will be providing care in some form of cover. So you don’t really need to wear the ninja suit. Secondly, even if you find yourself in this situation, it will be extraordinarily rare. You don’t need to be prepared for it every minute of every day, even if you are responding to scenes. None of the care providers during the Boston Marathon Bombing were all dressed up waiting for all hell to break loose as they providing special event care. Somehow they managed to do quite a great job.

But what about the others? The Fire Service is public safety. That is true, and in some places it also takes on the role of medical provider by virtue of EMS operations. But despite some misconception, they are 2 separate functions. The emergency medical care is healthcare. It is basically medicine, and even in initial schooling, the morals and ethics of medical care are taught and practiced. A medical provider is neutral in all respects. They are not there to judge a person. They are not there to enforce morals. They are not there to accuse or collaborate with authorities for prosecution. They are there to provide aid. Firefighters need to ask themselves “am I operating right now in the capacity of a medical person?” When the answer to that is “yes” they are not acting in a manner of public safety. The approaches, tools, and attitude must be that of medicine. Otherwise, they are no longer neutral, but an agent of the State. Those types of people are not too popular. I would go as far as to saying despised. Furthermore, even when acting as agents of the State, they are not law enforcement officers. They do not have powers of arrest, they are not obligated to take anyone into custody. Their authority is absolutely minimal. They certainly are not the moral police akin to the religious police forces of countries like Saudi Arabia.

EMS providers are medical providers. They are not public safety. This is where most confusion comes in. They have extremely limited public health roles. They have no law enforcement role. They do barely anything to protect the public at large. 99.9% of what they do is provide medical care to individuals. Even in massive disasters, triage and rationing are medical activities.

Some like to think they are public safety, I am not sure why? Maybe it makes them feel important. Maybe because they are publically funded and do not want to call themselves socialized healthcare. Maybe they think they are a part of some great institution. “The public safety forces” that sounds military! They are cool. Tacti-Kewl. Maybe they even have a military style uniform with some collar brass. Because you know, the EMS leader has the same responsibility and career chronology of say a admiral or general in the military. (or colonial or captain for that matter, equally laughable) Imitation is good flattery. You ever see one wearing a white lab coat? How about a white lab coat with collar brass? (or even a nurses hat with a red stripe) It must really make them feel like they belong to somebody. I just can’t satisfactorily understand why they need to do this.

Also in the event of major disaster, their primary role doesn’t change. They provide care to individuals. Nobody is giving albuterol treatments to a mass of people. Nobody is controlling the bleeding of society. Most doctors and nurses I know have more than 1 patient at a time, so even being forced to care for more than 1 is not “public.”

So who cares right? If they want to play make-believe, why should anyone stop them? Well… there is public perception. If they don’t want to be treated with public animosity and even violence as agents of the state, maybe they should stop acting like one? Maybe if they want people to trust them and respect them as “helpers” they could stop acting as moral judges and betraying the trust of patient/provider neutrality and confidentiality? Maybe if they want respect as healthcare providers by other healthcare providers they could start adopting their values instead of military ones? Maybe it is just good customer service?

Let’s reflect on that customer service aspect for a minute. Most elderly people do not want to see a doctor or a nurse with a rainbow Mohawk, face piercings, and full body tattoos. But doctors and nurses usually work in healthcare facilities, so people going to them (and in a way their home) have to accept some level of diversity they don’t like. But EMS is invited into the homes of others. They may not want to invite various people into their homes. When somebody they do not trust enters their personal space, it creates stress for them. Things like gender or race are not the decisions of providers. How they dress, how they act, body art, etc. are choices. What effect would tactically dressed EMS providers have on an elderly patient with chest pain? With Psychiatric patients? With even your common drunk? How would say a holocaust survivor react to a bunch of people in all black with helmets coming into their home to “help” them? How would people who came to your country from various warzones where soldiers who mistreated them dressed similar respond?

Let me ask this question? Do you think my ability to care for people is in anyway altered by what I wear to work? Do you think my knowledge or ability is altered based on if I am in the hospital or out of it? If mine is not, why would anyone else’s be? I don’t need to dress up like a soldier to help people. I don’t need to act like a cop to get respect from patients. Dressing up in an armored ninja suit like a Special Forces operator would not win me any respect from my colleagues in the medical community. So if you are a healthcare provider or acting in the capacity of one, why would you do it?
Life does not have to revolve around war. It is in fact nicer when it doesn’t. Perhaps you have never known or have forgotten? The military does not have the solution to your fears and anxieties. Not everything it does works in the non-military world. Nobody is trying to reinvent Sparta or another “military first” state like North Korea. If you don’t want people to respond violently to you, why would you dress and act like people who perpetrate violence on others? Why are you worried about patients you might see once in your lifetime instead of what you do everyday?

There is no such thing as “tacti-kewl”, it’s just being a whacker sometimes, while wearing a ninja suit. Set the example, if you don’t want others going around pretending to be military, don’t do it yourself. By the way, pretending to be a police officer is a criminal offense most places. Acting like or being a convicted criminal will not do much for your healthcare or public safety career.