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In a letter to the Memphis Firefighters Local#1784, FF/P Larry Boothby responds to the "You Call, We Haul" article published in an earlier version of BURNING ISSUES (The Official Publication of the Memphis Fire Fighters Association, IAFF Local# 1784, AFL-CIO-CLC)
"YOU CALL WE HAUL" CHALLENGED June 13, 2001
Dear Mr. Oldham,
I just finished reading your column in the latest issue of Burning Issues, and I find it appalling that this type of thing would happen in our department. I do, however, disagree with the current policy of "they call, you haul" or we will beat you with the QA stick. Our problem in this department stems from a severe lack of training, not from laziness on the part of the paramedics.
Take this incident for example. A properly trained Paramedic, who was current in Pediatric Advanced Life Support (PALS), should be able to recognize the difference between a child with a cold, and a child in acute respiratory distress. Respiratory problems are a leading cause of death with children, and a great deal of time is spent in the PALS class learning to recognize the signs and symptoms of a child with impending respiratory failure. Unfortunately, the department's EMS training capability has been gutted. When the question of why Paramedics were not required to maintain PALS, Advanced Cardiac Life Support (ACLS), Basic Trauma Life Support (BTLS), and Pediatric Basic Trauma Life Support (PBTLS), management responded that it did not agree with "merit badges for Paramedics." I took this response to both the American Heart Association (they oversee the ACLS curriculum), and to the local emergency room physicians at LeBonheur Hospital. They were incredulous, and the LeBonheur physicians group drafted a letter to our medical director stating that they were very concerned over the lack of PALS training among the MFD Paramedics... The reason this is such an important issue is that these courses of instruction are the standard of care nationwide. If you don't believe me talk to any emergency room nurse, physician, or Paramedic (outside of MFD). If you do, I believe you will find that our current level of training is dismal at best.
In a column of the MFD Siren, it was stated that we had the best EMS system in the state. Sadly, this is not true. I have worked in Chattanooga for both private and third service providers, and I can tell you that they have better trained, and more aggressive Paramedics, as well as more aggressive protocols and standing orders. The reason is that they have dedicated EMS training to keep their paramedics abreast of the latest medical knowledge, including ACLS, PALS, BTLS, and PBTLS. Even in Shelby County the paramedics who work for Rural Metro have better continuing education than we do. In addition to the previously named courses, their Paramedics are required to maintain National Registry certification, which is more rigorous than what we have through the State. Even a small town like Idaho Falls, Idaho, has higher standards than we do. Two weeks ago I was there and spoke with the FD Paramedics. They are required to maintain ACLS, and they have agreements with the local hospital to allow them to go in and perform skills that are rarely used in the field. These hospital sessions are required by their Fire Department as part of their continuing education.
Our mission statement includes the words "Teamwork with a Commitment to Excellence." Excellence starts with training. You cannot reasonably expect Paramedics to do this job well if you are unwilling to train them. Emergency medicine is an evolving science that undergoes rapid changes. This is why the top medical experts in the country developed ACLS, PALS, BTLS, and PBTLS courses, and why the certifications are only good for two years. It is also why hospitals and EMS agencies nationwide provide this training to their employees and require that they attend. That's the teamwork part. The departments provide it and the Paramedics take it into the field to their patients.
The death of any child is a tragedy. This situation is also a disgrace. Under the current philosophy of they call, we haul, or else, it will happen again. The solution to our problem is a combination of training and the "or else." This department needs to make the "Commitment to Excellence" and start training its Paramedics and EMTs to provide the world class care that the citizens of Memphis deserve. Otherwise they should get rid of the ambulances and Paramedics, and get a fleet of taxis and cab drivers to "haul" the citizens who call 911.
Sincerely, Larry G. Boothby Firefighter/Paramedic
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MEDICAL DIRECTOR RESPONDS I read Mr. Boothby's rebuttal in the November 2001 Issue. Several areas of his letter deserve comment. I consider education as one of the most vital aspects of healthcare. I also believe that the purpose of education is to help each of us develop an objective and impartial thinking process that will free our creative minds. To that end, each of our state certified paramedics have had ample instruction in the care and treatment of patients calling for assistance. Each paramedic understands the personal and professional responsibility to acquire new knowledge in their area of expertise, out-of‑hospital care. They also recognize the necessity to maintain their skills to the best of their ability. If they have deficits in their knowledge after they have passed the state exam, only they will know where the deficits are. They have a duty to remedy their deficit. That is the very essence of being a professional. The courses cited by Firefighter/ Paramedic Boothby such as Pediatric Advance Life Support (PALS), Basic Trauma Life Support (BTLS), and Pediatric Basic Trauma Life Support (PBTLS) are all courses that are open to the public. Any EMT or paramedic can attend if they so choose. However, the administrators of these courses make it clear that completion of the activities related to these programs in no way confers competence in any of the areas. The administrators also make it clear that they are giving guidelines for care in critical situations not promulgating rigid standards for prehospital management of disease or injury. Mr. Boothby also makes an assertion that our paramedics are less well trained than others in our region. That is not true. Other areas such as Nashville have the same training complication as we. The` students in Nashville must go to Cookeville to learn how to intubate, for the Nashville area hospitals cannot provide that training to them. Similar stories are seen in other locals. I am proud of our paramedics and believe the greater majority is excellent. They provide a great service to the community and they are there when we need them. Mr. Boothby also makes the assertion that more aggressive is better. He loses site of the fact that invasive procedures are difficult to perform and are rarely if ever indicated in the field. Currently, rapid sequence intubation (RSI) in the field is being evaluated by the State. Over 250 or more patients have been reported to have had RSI. Only two cases showed an inability to intubate the patients. Interestingly enough, it was the consensus of opinion by the Clinical Issues Committee that the data could not be representative of the actual activities for more complications should have been reported. Twelve cases of RSI were reported by an ambulance service in which no medication was used to intubate the patient. These 12 were not RSI cases at all, showing the confusion about standards and the use of terminology. I gave Mr. Boothby a challenge over one year ago. I asked him to provide me any studies that would support his contention that paramedics that attend and pass ACLS have a greater success rate in cardiac resuscitation than those who did not attend. He has yet to provide any such data. I suspect the same would be true if I opened the request up to all short course training programs such as PALS and PBTLS. For the record, I have never received a letter from LeBonheur physicians concerning the lack of PALS training. PALS is for in‑hospital personnel and is not directed towards our concerns for the prehospital care setting. I agree with Mr. Boothby, the death of any child is a tragedy. Since I do not know the particulars of the court decision, I cannot judge the ruling or the merits of the case. I am having some difficulty making the connection between taking patients to the hospital and his belief that those actions will in some way bring another judgement against our EMS providers. The department has a "Commitment to Excellence," and I believe, for the most part, our paramedics strive to exceed the standard whenever they can. In closing, I challenge Mr. Boothby to help make the system better. If there are areas in our EMS system that he believes need to be improved, I ask him to give insightful solutions about them. If he knows of paramedic protocols that may help provide better care for our citizens, I ask that he submit them for review. Excellence does not start with training. Excellence is rooted in self‑motivation and responsibility. Excellence is not destination, but journey. We all have a responsibility to each other to be the best we can be at any one time. Perhaps the critics of our EMS system can provide the leadership to the Division of Fire Services by getting more involved and making a contribution. It's not enough just to show up. Perhaps those who have the knowledge and expertise in EMS could help our fellow firefighter paramedics mature to a higher level. Maybe they could become role models and problem solvers instead of critics without answers or solutions. Perhaps those from within, who continue to throw bricks at our EMS system may one day use those same bricks to lay a foundation for a better future for all of us. It only takes a dedicated someone to see the opportunities.
Respectfully submitted,
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