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Letter from Idaho

I was in Idaho last week at the invitation of my friend Gordy Kokx. Gordy and I go back a number of years, to when he was an assistant professor of EMS and I was the medical director at Central Florida Community College in Ocala. Since then, he has moved to Twin Falls, where he spearheaded the development of a solid EMS Program at the College of Southern Idaho. He was kind enough to invite me to speak at the first Southern Idaho EMS Conference. It was good to see Gordy, and nice to find out exactly how much he valued our friendship. The college EMS patch he gave me still had a price tag on it. Let's just say I thought a shared history might at least reach double digits.

I had never been to Idaho, so Deb Lauer from the college was kind enough to send me a stack of tourist brochures. It looked wonderful. Tall mountains, outdoor sports, lots of wildlife and not one potato in sight. So I dug my warm winter jacket out of storage, found a pair of long-neglected gloves and retrieved the walking boots from the garage. If it snowed, I was skiing; if not, a-hiking I would go. I was ready.

I got off the plane in Twin Falls and looked for the mountains. I kept looking. It turns out that most of Southern Idaho is as flat as my beloved Kansas, with a few notable exceptions. One of them is the 500 foot chasm just north of town known as the Snake River Canyon, spanned by a steel arch bridge one of the few authorized places for base jumping in the country. It's really pretty amazing. You drive up this nondescript commercial street, pass the mall and, suddenly, the earth opens up before you. It's pretty cool. At the Hagerman Fossil Beds National Monument Visitors Center (where I had my picture taken with the Hagerman Horse, the Official Fossil of the State of Idaho) I learned that the entire gorge was cut during an eight-week flood 15,000 years ago. That's faster than most marriages in Vegas.

Because this is Idaho, I did learn something about potatoes. In the town of Buhl ("Trout Capital of the World"), I came across Smith's Dairy, which advertised that it had potato ice cream. So I stopped in, and the beautiful young heartbreaker-to-be behind the counter (made me wish I was still in high school ... of course, that means I would have flunked 23 years running) advised me to try a taste of "coffee potato." As I wrapped my taste buds around the frozen concoction, she explained to me that it had to be coffee potato, or else it wouldn't have any flavor at all. In the end, I went for peach ("It's the best, if you can ignore the radiation orange color," explained my wish-for-younger-days). The coffee potato needed butter.

(As she scooped up my snack, she told me that she had a contest going with her friend over who could get the most signatures in her guest book. I signed in, and I encourage everyone who can to send a card with a signature to Smith's Dairy, 205 Broadway Avenue South, Buhl, Idaho, 83316. If we all work together, the onslaught of mail will be the biggest thing to hit Buhl since the flood of 13,997 B.C.)

One of the keynote talks at the meeting was by Michael Morrow, an EMS educator from Cleveland (I think that if you're a speaker, it helps to be from Cleveland, because the audience is instantly sympathetic to your plight). He spoke on ethics in EMS with all the big-city abrasiveness one might expect from someone who lives where the Cuyahoga River once caught fire. But his real message was one of personal responsibility and accountability.

Mr. Morrow opined that the youth of today are a problem. Reflecting upon his own upbringing, and that of most of his (and my) generation, he notes that many of the standards of conduct have changed. Language for which kids were once punished is now sanctioned, if not encouraged. Corporal punishment is frowned upon at home and banned in the public schools. The problem with kids, he argues, is a lack of moral accountability. With no standards for right and wrong and no consequences distinguishing acceptable from inappropriate behavior, he fears that the EMS providers of the future will carry this attitude with them to patient care. (Of course, he's sure to note that HIS kids didn't turn out this way.)

In all honesty, I think he was harsh in his statements, and his examples and analogies made me distinctly uncomfortable. Perhaps it was just his way of getting our attention, or it could be that I've been softened by political correctness. Maybe I wish I could have gazed at someone with assets like Britney Spears while in the throes of my own hormonal adolescence. But I think the key difference between Mr. Morrow and me is the classic contrast between the pessimist and the optimist. As the former, Mr. Morrow sees only a future of gloom and disaster: The past was better, and we must make a behavioral turn back to those days to rescue our children. In contrast, I want to look forward. Languages, for example, grow and change as part of a natural evolution. Advancing the way we treat our children and looking for less painful but more effective means of discipline should be the goal of all parents. If we accept Mr. Morrow's argument, the past must always be better, for the differences between generations are necessarily negative. I don't think this is the case, and a historical view might show this premise to be both uniformly accepted yet categorically wrong. If I needed any further proof, all I have to do is look into my son's eyes hopeful, full of promise, brimming with the desire to love and be loved, a wish inherent in all of us but manifested best in a child.

However, Mr. Morrow's key point is well taken. There must be a baseline level of acceptable behavior to which one is held accountable. While we may differ over whether this baseline is best held static throughout time, constantly in flux with society's whims, or some combination of the two, at heart one must still be accountable for one's own actions. This is true in both personal life and professional responsibilities.

For you, the EMS provider, professional accountability is crucial. There are two components to this mandate. The first is what I'll term as structural accountability, or those components of the EMS system external to the individual to which you must answer. These elements include your medical director, your EMS system, your prehospital peers, and the expectations of the community you serve. Internal accountability, on the other hand, is how you accept responsibility for your own actions and is manifested by your personal code of ethics. If we consider that ethics are the behavioral rules that stem from our personal values and beliefs, then a belief in personal accountability will necessarily produce ethical behavioral. (Fear of external punishment may produce acceptable behavior as well, but if the underlying belief structure is not consistent with the mandated behavior, motivation suffers. One then strives for minimum adherence to norms, rather than to achieve exemplary attitudes and behaviors.)

It seems clear that a belief in personal accountability leads to ethical behavior, and ethical behavior demands continual excellence in patient care. However, in the course of our daily efforts, our motivation often wanes. Internal codes of conduct may not match the behaviors and attitudes we express.

We need to rededicate ourselves to the ideal of personal accountability, and to conducting ourselves in a consistently exemplary manner. We do this not only for ourselves, but also for the next generation of EMS. Mr. Morrow is right to conclude that if we do not act as role models, the EMTs and paramedics who follow us will have no concept of what constitutes acceptable language, demeanor, and care. And if (for the moment) we accept Mr. Morrow's premise that these role models are not coming from the culture or home, they must come from the workplace if future generations of paramedics hope to maintain the respect and trust they now enjoy.

I would be remiss if I ended my tale without saying something about the good people at the conference. Idaho is a rural state, and the vast majority of providers operate at the first responder or BLS level. Most do so as volunteers, on their own time and at their own expense, out of a heartfelt desire to serve their friends and neighbors. I met people who live in hamlets of less than 100 people and others who drove eight hours for a single day of sessions. They were there because they wanted to learn, to excel and to be a better resource for their communities in times of need. Their boundless enthusiasm for EMS was infectious. How very different, and very refreshing, from the well-paid, well-regimented, but often bored and disinterested "professionals" many of us know. There's a new spark in my fire for EMS. Thanks, Twin Falls.


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